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HEART  AFFECTIONS 

USED  AT  BAD-NAUHEIM 


BEING    A    TRANSLATION    OF 

"DIE   GYMNASTIK   DER    HERZLEIDENDEN" 
VON 

DR.    MED.   JULIUS  ^HOFMANN    UND 
DR.  MED.  LUDWIG  POHLMAN 

BERLIN    UND    BAD-NAUHEIM 


By  JOHN  GEORGE  GARSON,  M.D.  EDIN.,  &c. 

PHYSICIAN    TO    THE    SANATORIA    ANO     RA  U-N  AUHCIM,    EVERSLEY,    HANTS 


FIFTY-ONE  FULL-PAGE  ILLUSTRATIONS  AND  DIAGRAMS 


PAUL     B.    HOEBER 

69    EAST   59   STREET 

NEW   YORK 

191 1 


72] 


TRANSLATOR'S    PREFACE   AND 
INTRODUCTION 

THE  physical  methods  of  treatment  of  affections  of  the  heart 
have  made  such  marked  advances  in  Germany  during  the 
last  twenty  years  that  they  can  no  longer  be  regarded  as 
the  elaboration  of  a  few  enthusiasts.  The  relative  rapidity 
with  which  these  methods  have  come  to  be  recognised  as 
therapeutical  measures  of  the  first  importance  has  no  doubt 
been  greatly  due  to  the  existence  there  of  natural  thermal 
springs,  highly  charged  with  carbonic  acid  gas  and  salines 
specially  suitable  for  bath  purposes  in  cardiac  affections. 
The  success  which  has  attended  the  use  of  these  waters  as 
baths  in  conjunction  with  certain  remedial  gymnastics, 
selected  on  well-thought-out  physiological  grounds,  has  been 
so  great  as  to  constitute  a  new  chapter  in  the  practice  of 
Medicine  relative  to  the  treatment  of  heart  affections.  The 
greatest  enthusiast  of  these  methods  would  not  pretend  to 
credit  them  with  the  powers  of  restoring  to  health  and 
strength  persons  whose  hearts  and  blood  vessels  are  hope- 
lessly damaged  and  beyond  repair.  But  fortunately  these 
are  not  the  majority  of  the  cases  met  with  in  practice. 
Affections  of  the  heart,  as  a  rule,  are  attended  with  sufficient 
discomfort  to  the  patient  to  cause  him  at  an  early  period  to 
seek  medical  advice  while  the  affection  is  still  amenable  to 
treatment,  or  at  least  while  the  condition  of  the  patient  can 
be  materially  improved.  As  experience  has  been  gained  in 
their  use,  the  physical  methods  of  treatment  have  been  im- 
proved and  placed  upon  a  firmer  physiological  basis  ;  their 
capabilities  also  have  been  more  exactly  ascertained  and 
their  limits  of  usefulness  more  accurately  defined.  In  this 


- 

SOS  flflCEUES, 


viii  TRANSLATOR'S    PREFACE 

advancement  of  knowledge  successive  physicians  at  Bad- 
Xauheim  have  played  so  important  a  part  that  the  treatment 
has  become  peculiarly  associated  with  that  health  resort  and 
with  the  name  of  the  late  August  Schott  who  did  so  much, 
especially  in  early  days,  to  evolve  its  principles  and  establish 
its  practice. 

In  England  the  adoption  of  these  new  methods  has  been 
very  slow.  It  is  true  that  in  most  recent  text-books  dealing 
with  heart  affections  reference  is  made  to  the  Nauheim 
treatment,  and  the  exercises  elaborated  by  Schott  are 
frequently  described.  The  latter  are  also  taught  to  pupils 
of  massage.  But  notwithstanding  the  commendations  of 
several  of  our  leading  Physicians,  both  in  their  practice  and 
in  their  published  works,  it  cannot  be  gainsaid  that  great 
scepticism  prevails  in  the  medical  profession  of  this  country 
as  to  the  value  of  the  methods,  and  comparatively  few 
practitioners  of  medicine  are  personally  acquainted  with 
them.  In  Great  Britain  and  Ireland  we  have  no  natural 
springs  highly  charged  with  carbonic  acid  gas  comparable 
to  those  of  Bad-Xauheim.  To  carry  out  the  treatment, 
therefore,  as  regards  baths,  artificial  means  of  charging 
the  water  with  the  salts  and  gas  have  to  be  resorted 
to,  or  patients  have  to  go  to  Bad-Nauheim  to  obtain 
them.  Although  for  several  years  past  the  number  of 
patients  who  have  resorted  thither  has  averaged  about 
one  thousand  annually,  this  is  but  a  very  fractional  propor- 
tion of  the  cases  that  would  be  benefited  by  the  treatment. 
Differences  of  language,  habits,  and  customs,  as  well  as 
distance,  must  ever  be  formidable  barriers  in  the  way  of 
patients  going  to  Bad-Nauheim  for  treatment.  The  attempts 
which  have  been  made  to  prepare  the  baths  artificially  at 
home  have  for  various  reasons  not  been  very  successful, 
although  with  proper  apparatus  for  charging  the  water  and 
by  the  addition  of  chemicals  in  the  proper  proportion  there 
is  absolutely  nothing  to  prevent  the  treatment  being  carried 


TRANSLATOR'S    PREFACE  ix 

out  in  its  entirety  with  equal  success  in  England  as  at  Bad- 
Nauheim,  once  the  methods  have  been  learned.  It  is  being 
done  successfully  all  over  Germany.  The  fact  must  also 
be  learned  that  properly  charged  carbonic  acid  baths  cannot 
be  obtained  by  passing  the  gas  through  the  water  in  the 
bath,  or  by  adding  chemicals  to  generate  the  gas  in  the 
water  of  the  bath.  To  get  the  proper  effects  of  carbonic 
acid  baths,  it  is  essential  that  the  water  used  for  the  bath  be 
charged  with  the  gas  under  pressure,  so  that  the  latter  takes 
the  place  of  the  atmospheric  air  naturally  held  in  the  water. 
The  machinery  required  for  this  is  expensive,  and  a  pro- 
perly equipped  bath-house  is  necessary.  Hospitals  in  this 
country  have  not  yet  been  provided  with  such  appliances, 
and,  therefore,  but  few  practitioners  of  medicine  have  had 
an  opportunity  of  seeing  the  physical  methods  carried  out. 
Yet  those  of  us  who  have  had  the  opportunity  of  studying 
them  thoroughly,  know  and  realise  the  powerful  effect  for 
good  or  evil  they  possess,  accordingly  as  they  are  used 
rightly  or  wrongly.  The  action  on  the  heart  of  the 
Nauheim  baths  and  exercises  is  sometimes  so  powerful  that 
in  some  cases  we  may  be  able  to  obtain,  by  means  of  the 
one  or  the  other,  in  a  few  minutes,  the  effect  we  have  been 
trying  in  vain  for  weeks  to  bring  about  by  means  of  drugs. 
With  remedies  which  may  in  some  cases  act  so  promptly 
and  potently,  caution  is  very  necessary  even  when  the 
physician  is  skilled  in  their  use.  And  just  as  we  do  not 
entrust  potent  drugs,  such  as  hydrocyanic  acid,  digitalin, 
strychnine,  etc.,  to  the  hands  of  even  trained  nurses,  except 
under  strict  medical  direction  and  supervision,  so  the 
physician  himself  should  always  personally  direct  the 
administration  of  these  physical  remedies  when  beginning 
them  on  a  patient,  and  carefully  judge  the  effect  they  are 
producing.  After  he  is  satisfied  as  to  their  action  on  the 
patient,  he  may  by  degrees  avail  himself  of  the  assistance 
of  a  trained  attendant,  working  under  his  supervision,  in 


x  TRANSLATOR'S    PREFACE 

carrying  them  out.  The  medical  profession  and  the  public 
cannot  be  too  strongly  warned  against  the  dangerous  conse- 
quences liable  to  occur  from  attempts  being  made  to  carry 
out  these  physical  methods  of  treatment  in  Nursing  Homes 
by  persons  who  are  not  qualified  medical  practitioners, 
whose  only  knowledge  of  them  often  is  that  they  may  have 
learned  the  movements  of  the  different  exercises  while 
going  through  a  course  of  instruction  in  massage,  and  who, 
on  the  strength  of  this,  advertise  their  Homes  as  places 
where  Nauheim  treatment  can  be  obtained.  The  qualified 
medical  practitioner  will  find  that  he  has  much  to  learn 
regarding  the  administration  of  the  remedial  gymnastics 
when  he  first  begins  their  use.  He  should  never  begin  by 
practising  them  on  a  person  whose  heart  is  affected.  At 
first  he  is  very  prone  to  perform  the  movements  too  rapidly, 
and  to  offer  too  much  resistance  when  he  attempts  resisted 
movements  on  the  patient.  It  is  only  after  considerable 
practice  that  one  comes  to  know  instinctively  the  details, 
and  is  able  to  observe  from  the  appearance  of  the  patient 
whether  or  not  too  much  is  being  done.  Even  when  there 
are  no  indications  of  strain  it  is  not  prudent  to  rely  on  visible 
symptoms,  and  the  means  subsequently  described  in  the 
text  should  always  be  taken  to  test  and  control  the  effect  of 
the  gymnastics  on  the  patient. 

This  edition  of  Dr.  Hofmann's  work  is  presented  in  the 
English  language  with  the  hope  that  it  may  be  of  assistance 
to  members  of  the  medical  profession  who  are  desirous  of 
making  themselves  acquainted  with  that  part  of  the  Nauheim 
methods  of  treatment  of  heart  affections  which  can  be 
carried  out  in  ordinary  medical  practice,  and  which,  in  suit- 
able cases,  gives  excellent  results,  independently  of  the 
Baths.  When  the  latter  are  also  available,  under  medical 
supervision,  the  range  of  usefulness  of  the  treatment  is 
vastly  extended,  and  in  many  cases  the  combined  treatment, 
sometimes  in  conjunction  with  special  massage,  gives  the 


TRANSLATOR'S    PREFACE  xi 

best  results.  Before  undertaking  the  task  of  translating 
this  work  I  had,  by  personal  visits  to  Bad-Nauheim,  oppor- 
tunities of  making  myself  thoroughly  acquainted  with  the 
various  methods  and  appliances  for  treatment  employed 
there,  and  of  discussing  and  testing  the  objects  and 
relative  values  of  the  several  remedial  gymnastics  selected 
for  use  by  Dr.  Hofmann  in  his  splendidly  appointed  Sana- 
torium. Although  in  the  main  these  gymnastic  exercises 
are  the  same  as  the  series  propounded  by  the  late  August 
Schott,  several  modifications  and  improvements  have  been 
effected  since  his  death  in  the  mode  of  carrying  them  out, 
new  exercises  have  been  added,  and  some  of  the  original 
ones  have  fallen  into  disuse.  Subsequent  experience  in  the 
series  recommended  in  this  work  has  confirmed  the  favour- 
able opinion  I  formed  of  them,  and  I  have  used  them  alone, 
and,  more  recently,  since  1  got  the  Nauheim  Bath  Institute 
established  at  Eversley,  in  conjunction  with  the  baths,  with 
much  success. 

In  the  translation  of  Dr.  Hofmann's  text  I  have  adhered 
as  closely  to  the  original  as  the  idioms  of  the  languages 
would  permit,  but  in  the  descriptions  of  the  gymnastic 
exercises  I  have  taken  greater  latitude,  and  in  some  cases 
have  remodelled  the  directions  entirely,  when  I  have  con- 
sidered that  by  so  doing  these  could  be  made  clearer  and 
more  simply  expressed.  In  two  instances  I  have  given 
alternative  directions,  which  from  practical  experience  I 

have  found  desirable. 

J.  G.  GARSON. 

THE  SANATORIA  AND  BAD-NAI  HEIM. 

EVERSLEY,  HANTS, 

October,  1909. 


AUTHOR'S    PREFACE 

IN  the  course  of  the  development  of  modern  therapy  it  has 
been  proved  that,  in  the  treatment  of  many  diseases  of  the 
heart  and  blood  vessels,  the  same  successful  result  is  not 
always  obtained  by  the  same  means  in  different  cases.  In 
pharmaceutical  therapy  this  fact  has  long  since  been  recog- 
nised. It  is  therefore  not  to  be  wondered  at  that  the  same 
thing  should  also  hold  good  in  physical  therapy.  Thus, 
there  are  many  persons  suffering  from  heart  affections  with 
whom  carbonic  acid  baths,  in  any  form,  do  not  agree. 
These  patients,  on  the  other  hand,  very  often  show  an 
excellent  reaction  to  oxygen  baths,  or  electrical  manipula- 
tions, especially  to  the  alternating  current  baths.  Splendid 
results  can  also  be  obtained  from  certain  gymnastic  cures. 

But  in  heart  affections  a  therapy  may  be  wrongly  used. 
"Overdoing,"  for  example,  is  a  veritable  two-edged  sword, 
and  just  as  a  patient  with  heart  affection  can  be  benefited  by 
gymnastics  properly  used,  so  he  can  be  made  worse  by 
overdoing  it  or  by  a  wrong  use  of  exercises. 

We  have  now  collated  the  most  essential  exercises  for  a 
gymnastic  course  without  apparatus,  so  that  our  experience 
may  be  at  the  disposal  of  Physicians  and  the  public.  The 
book  has  been  written  from  practice  for  practice. 

DR.   MED.  JULIUS  HOFMAXX. 


CONTENTS 


PAGE 


Translator's  Preface  and  Introduction  .  ...     vii 

Author's  Preface  .  .  ...    xiii 

CHAP.    I.     Introduction — The    Chief    Systems    of    Remedial 

Gymnastics  used  in  Heart  Affections  .  .          .        i 

CHAP.   II.      Indications  for  and  against  the  Use  of  Remedial 

Gymnastics  and  Baths  in  Heart  Affections    .  4 

CHAP.  III.  Medical  Supervision  Necessary  and  Methods  of 
Controlling"  the  Effects  of  Gymnastics  on  the  Patient — 
Observations  on  the  Pulse  .  .  9 

CHAP.  IV.  Testing  the  Effects  of  Gymnastics  by  Observa- 
tions on  Blood-pressure,  Auscultation,  Percussion, 
Rontgen  Rays  .  .  .  18 

CHAP.  V.     Testing  the  Influence  of  Gymnastics  by  Sommer's 

Analysis  of  Movements — Observations  on  the  Respiration     23 

CHAP.  VI.     The  Different  Ways  in  which  Gymnastics  may  be 

Used — Their  Object         .  .  .  .          .     31 

CHAP.  VII.  The  Order  in  which  the  Gymnastics  should  be 
Practised  and  their  Object  —  Special  Exercises — The 
Importance  of  Breathing^  Properly  during  the  Exercises 
—The  Clothing  during  and  after  Exercises — Diet  and 
Stimulants  .  .  .  .  •  •  35 


xvi  CONTENTS 

GYMNASTIC    EXERCISES 
A.     PASSIVE,  IN  LYING  POSITION 

PAGE 

1.  Forearm-bending.                  .                  .  42~45 

2.  Arm  abduction       .                  .                  .  46-47 

3.  Rotation  outwards  of  feet     .                  ...  48 -49 

4.  Abduction  of  lower  limbs     .                  ...  5O-51 

5.  Abduction  and  rotation  of  lower  limbs             .          .  52  53 

6.  Flexion  of  leg  and  thigh       .                  .              •          •  54  57 

7.  Raising  lower  limbs               .                  .              .          .  58  59 

8.  Trunk-raising  from  horizontal               .              .          .  60  61 

B.     ACTIVE,  IN  STANDING  OR  SITTING  POSITION 

9.  Flexion  of  forearm                 .                  .  62  63 

10.  Extenso-flexion  of  forearm  .                  ...  64 -65 

1 1 .  Horizontal  extension  and  spanning  of  arms    .          .  66  69 

12.  Forward  and  upward  stretching  of  arms         .          .  70  73 

13.  External  and  upward  stretching  of  arms         .          .  74  77 

14.  Backward  stretching  of  arms                .             .          .  78-79 

15.  Forward  thrusting  of  forearms             .              .          .  80  8 1 

1 6.  Rotation  of  upper  arm  with  forearm  bent        .          .  82-85 

1 7.  Rotation  of  extended  arm    .                  ...  86-87 

18.  Extension  of  leg  .                  .                  ...  88-91 

19.  Knee  abduction  and  adduction              .              .          .  92~95 

20.  Leg  flexion             .                  .               *•.              .          .  96-97 

21.  Thigh  flexion          .                   .                   ...  98-101 

22.  Thigh  extension    .                  .                  ...  102-105 

23.  Leg-raising  sideways  (abduction)         .              .         .  106   107 

24.  Trunk-twisting      .                  .                   ...  108    in 

25.  Trunk-bending — sideways    .                  ...  112-113 

26.  ,,             ,,           forwards    .                  ...  114   117 

27.  ,,              ,,           backwards                   .              .          .  118-121 

28.  Trunk-raising  with  apparatus                .              .          .  122-123 

Index  i ?r 


REMEDIAL  GYMNASTICS 
FOR  HEART  AFFECTIONS 

CHAPTER    I 

2.  2732. 

Introduction — The  Chief  Systems  of  Remedial  Gymnastics  used  in 
Heart  Affections. 

i( 

T~)  EMEDIAL  gymnastics  are,  as  a  rule,  suitable  only  in 
AX.  certain  cases  of  heart  affection,  and  the  physician  has 
always  to  consider  very  carefully  whether  or  not  the  patient 
is  able  to  endure  the  exertion  they  entail.  Other  patients, 
again,  are  best  suited  by  remedial  gymnastics  of  a  very 
special  kind.  "Nee  nemis"  are  the  words  of  warning  which 
should  ever  be  present  in  the  mind  of  the  physician  when 
prescribing  gymnastic  exercises.  The  reason  for  this  is 
that,  while  much  good  can  be  effected  by  the  proper  use  of 
them,  they  may  cause  just  as  much  harm  to  the  patient 
when  wrongly  employed.  As  an  illustration  of  this  we  need 
only  mention  the  injurious  effects  which  have  often  resulted 
from  the  M tiller  exercises  on  previously  healthy  hearts. 

Before  proceeding  to  indicate  which  remedial  gymnastics 
are  in  our  opinion  the  most  suitable  for  heart  affections  we 
must  consider  the  following  questions  :— 

1.  Which  are  usually  considered  the  best  remedial  gym- 

nastics for  heart  affections? 

2.  Are  several  systems  equally  good  ?     If  so,  which  is  the 

least  expensive  and  generally  the  most  practicable 
for  the  patient  to  carry  out  wherever  he  may  be  ? 

3.  In   what   affections  of  the  heart  should  treatment  by 

remedial  gymnastics,  as  a  rule,  be  avoided,  and 
which  exercises  should,  in  certain  cases,  in  the 
interests  of  the  patient,  be  omitted? 

The  answer  to  the  first  question  is  that  there  are  three 
systems  of  remedial  gymnastics  which  specially  claim  our 


2      GYMNASTICS    FOR    HEART   AFFECTIONS 

attention,  namely,  that  of  the  distinguished  Austrian  Herz, 
the  Swedish  remedial  gymnastics,  and  that,  also  of  Swedish 
origin,  elaborated  more  especially  by  the  late  August  Schott. 
A  fourth  method,  the  Oertel  Terrain  cure,  must  be 
mentioned,  though  it  is  not  on  a  par  with  any  of  the  other 
three  systems  just  named.  The  absence  of  supervision 
during  exercise,  not  being  able  to  take  rest  immediately  on 
the  appearance  of  fatigue,  and  the  long  interval,  at  least 
twenty-four  hours,  which  has  to  elapse  before  the  exercise 
can  be  repeated,  make  the  Terrain  cure  generally  impractic- 
able. Again,  for  a  Terrain  cure,  the  invalid  has  to  walk 
a  certain  distance  along  a  road,  and  then  back  to  the 
place  from  which  he  started.  Should,  for  example,  a 
walk  of  one  hour  have  been  prescribed  for  the  Terrain 
cure,  and  the  patient  have  reached  the  furthest  point  to 
which  he  has  to  go,  situated  at  a  distance  of  half  an  hour 
from  his  home,  it  is  a  very  unpleasant  experience  for  him 
if  he  then  finds  himself  suddenly  overtaken  by  fatigue. 
He  has  still  half  an  hour  to  walk  before  he  can  get  home, 
and,  by  that  time,  may  be  in  a  very  exhausted  condi- 
tion. In  a  remote  sanatorium  at  which  the  author  was 
formerly  an  assistant  he  has  several  times  seen  this  actually 
occur,  when,  in  consequence  of  the  condition  of  the  patient 
appearing  to  be  better  than  it  really  was,  too  long  a  walk 
had  been  prescribed,  or,  as  more  frequently  happened,  when 
patients  of  their  own  accord  took  longer  walks  than  they 
should  have  done.  He  has  repeatedly  seen  patients  who 
were  undergoing  a  Terrain  cure  brought  home  on  a  hay 
wagon  in  an  extremely  exhausted  condition.  That  in  itself 
would  not  have  been  so  serious  did  not  the  overstrain  always 
delay  the  success  of  the  cure.  The  Terrain  cure  can  only  be 
taken  in  safety  in  grounds  surrounding  a  residence  on  roads 
specially  constructed  for  the  purpose,  and  arranged  so  that 
the  walk  can  be  stopped  at  any  time  and  rest  taken  forthwith 
on  the  appearance  of  fatigue. 


INTRODUCTION  3 

We  need  therefore  only  consider  the  three  systems 
previously  mentioned,  and  of  these  the  last-named  is,  with 
certain  modifications  and  some  omissions,  in  our  opinion, 
the  most  serviceable.  In  making  this  selection  we  are  far 
from  depreciating  in  any  way  the  value  of  the  Herz  and 
Zander  systems  of  remedial  gymnastics,  but  the  system 
which  we  more  particularly  favour  requires  no  apparatus, 
and,  if  the  patient  wants  assistance,  it  can  be  rendered  to  him 
by  a  member  of  his  family,  a  servant,  or  a  friend.  For  the 
other  two  systems  very  costly  apparatus  is  in  part  necessary. 
In  a  sanatorium  all  the  three  systems  are  equally  valuable, 
but  for  home  use  that  to  which  we  have  given  the  preference, 
because  of  its  requiring  no  apparatus,  being  equally  good, 
simple,  and  the  cheapest,  is,  in  our  opinion,  most  to  be 
recommended. 

If  a  patient  is  physically  fit  to  undergo  gymnastic 
treatment,  he  should  in  his  own  interest  place  himself  for 
some  time  under  the  care  of  a  physician,  or  in  a  well- 
conducted  medical  institute,  to  learn  how  he  should  do  the 
gymnastics  and  which  exercises  are  most  suitable  for  him. 
He  should  explicitly  follow  the  instructions  of  the  physician 
under  whose  supervision  he  is,  and  learn  by  heart  the  direc- 
tions given  him.  "Do  such  and  such  an  exercise  in  this 
way  and  for  so  long."  "In  this  exercise  take  a  deep  breath 
at  this  point,"  etc.  During  the  first  few  weeks  the  effect  of 
each  gymnastic  exercise  should,  if  possible,  be  controlled  by 
the  physician,  so  that  he  may  add  further  exercises,  or  stop 
such  as  are  not  suitable  for  the  patient.  Should  at  any  time 
the  patient  find  that  an  exercise  causes  him  any  abnormal 
sensation,  he  should  not  console  himself  with  the  idea,  "Oh, 
it  will  soon  pass  off,"  but  should  at  once  discontinue  the 
exercise  and  consult  his  physician.  This  is  especially  neces- 
sary at  the  beginning  or  if  the  patient  is  not  under  the 
immediate  supervision  of  the  physician. 


CHAPTER    II 

Indications  for  and  against  the  use  of  Remedial  Gymnastics 
and  Baths  in  Heart  Affections. 

WE  have  now  to  consider  the  fundamental  principles  in- 
volved in  the  answer  to  the  question,  Who  should 
avoid  gymnastics  and  who  should  use  them?     This  question 
has  been  answered  by  Romberg,1  of  Tubingen,  in  a  short 
and  concise  paper  in  the  following  manner  : — 

"Turning  now  to  the  indications  and  centra-indications, 
it  follows  from  what  has  just  been  said  that  both  methods  of 
strengthening  the  heart  [baths  and  gymnastics]  are  only 
suitable  in  the  initial  stage  of  the  disease.  It  is  only  then 
that  the  heart  possesses  a  certain  definite  store  of  reserve 
strength  with  the  help  of  which  it  will  be  able  to  respond  to 
increased  demands  cautiously  made  upon  it.  If  the  stage 
of  severe  disturbance  of  the  circulation  has  already  begun, 
if  the  heart  is  already  during  rest  no  longer  in  a  position 
to  maintain  an  approximately  normal  circulation,  if  there  be 
continuous  and  severe  dyspnoea  during  rest,  if  persistent 
oedema  and  effusion  into  the  body  cavities  be  present,  then 
baths  and  gymnastics  are  no  longer  suitable  for  the  patient. 
After  the  heart  has  materially  improved  they  may  perhaps 
be  considered  desirable.  Equally  unsuitable  are  patients 
suffering  from  pronounced  angina  pectoris  and  attacks  of 
cardiac  asthma,  as  experience  shows  that  dangerous  attacks 
may  be  brought  on  by  any  increased  demand  on  the  heart. 
Similarly  unsuitable  also  are  cases  in  which  fresh  dis- 
turbances have  occurred  after  manifest  over-exertion  or  after 
an  infectious  disease.  These  are  benefited  only  in  their  later 
stages  by  the  treatment. 

1  "  Uber  die  physikalischc  und  di;ltetische  Behandlung  der  Herzkrankheit," 
Prof,  von  Romberjc,  Tubingen.  Medizinisches  Korrespondensblatt  dcs  tvilrt- 
ttmbergischen  iirztliclicn  Laiidesverht,  Hd.  77,  \r.  26,  vorn  29  Juni  1907. 


INDICATIONS    FOR   AND   AGAINST  5 

"Great  attention  should  be  given  to  the  condition  of  the 
vascular  system.  When  considerable  arterio-sclerosis  is 
present  and  the  blood-vessels  are  consequently  more  or  less 
incapable  of  adapting  themselves  to  the  changing  demands 
upon  them,  we  must  remember  that  the  blood  requirements 
of  the  body  have  to  be  regulated  by  the  heart  much  more 
than  under  normal  conditions.  In  arterio-sclerosis  baths 
and  gymnastics  make  heavy  demands  on  the  heart,  espe- 
cially gymnastics,  so  that  in  pronounced  arterio-sclerosis  it 
is  better  to  avoid  resistance  exercises  entirely.  Gymnastics 
are  absolutely  contra-indicated  in  all  cases  in  which  chronic 
nephritis  is  present.  Such  patients  are  liable  to  violent 
fluctuations  of  their  vaso-motor  tonus.  In  them  the  de- 
mands on  the  heart  can  never  be  estimated  beforehand  with 
any  certainty.  If,  on  the  other  hand,  as  often  happens, 
cardiac  insufficiency  is  the  primary  disease  and  the  kidney 
affection  is  secondary  to  it,  such  patients  may  with  advan- 
tage be  treated  with  baths  and  gymnastics. 

' '  Further,  all  patients  to  whom  an  acceleration  of  the  blood- 
stream is  dangerous  are  naturally  precluded  from  baths  and 
gymnastics,  also  persons  who  have  had  even  a  slight  attack 
of  apoplexy,  persons  with  distinct  cerebral  arterio-sclerosis, 
and  persons  who  have  recently  recovered  from  embolism. 
If  the  condition  of  the  brain  improves  and  the  state  of  the 
heart  renders  bath  treatment  desirable,  I  advise  for  these 
patients  baths  of  medium  or  almost  medium  temperature 
which  do  not  contain  carbonic  acid  gas,  such  as  plain  and 
thermal  brine  baths.  Finally,  it  is  scarcely  necessary  to 
emphasise  the  fact  that  the  general  condition  of  the  patient 
should  be  taken  into  consideration,  and  that  those  who,  above 
everything,  require  rest,  especially  neurasthenics,  the  over- 
worked, the  exhausted,  and  the  very  emaciated  should  not 
be  put  through  a  severe  course  of  baths  or  gymnastics,  at 
least  at  the  beginning  of  the  cure. 

"  If  weakness  of  the  heart  occurs  in  a  person  who  has  led 
a  physically  very  active  life,  it  is  useless  to  expect  benefit 
from  gymnastic  exercises,  when  the  much  heavier  work 
required  of  the  heart  in  his  daily  occupation  has  not  averted 


6      GYMNASTICS   FOR    HEART   AFFECTIONS 

the  occurrence  of  insufficiency.  But  if  none  of  the  contra- 
indications already  enumerated  are  present,  and  especially 
if  there  is  no  contributory  overstrain,  we  may  well  expect 
good  results  in  cases  where  the  heart  of  a  muscularly  weak 
person  fails.  Thus  heart-weakness  in  a  muscularly  weak 
but  corpulent  young  person  with  no  arterio-sclerosis  is  very 
suitable  for  gymnastic  treatment.  In  these  cases  we  fre- 
quently see  most  excellent  results  from  strengthening  the 
heart  by  this  means. 

"Gymnastics  may  be  more  freely  prescribed  in  the  after- 
treatment  of  cases  in  which  the  heart-weakness  has  ceased 
to  be  active,  than  in  the  treatment  of  fresh  attacks.  In  the 
former  careful  gymnastic  treatment  is  often  a  very  good 
introduction  to  more  active  bodily  exercise,  of  course  only 
in  persons  without  pronounced  arterio-sclerosis,  also  more 
especially  in  young  people. 

"The  question  may  be  asked  whether  there  is  any  real 
necessity  for  the  physical  methods  of  treatment,  whether  the 
same  results  cannot  be  obtained  more  simply,  and  with  at 
least  equal  certainty,  by  means  of  drugs.  I  believe  the 
question  cannot  be  answered  in  a  word.  The  mode  of 
action  of  each  is  very  different.  Drugs  enable  the  heart  to 
utilise  more  of  its  available  strength.  Whether  by  con- 
tinued use  they  increase  the  sum  total  of  the  heart's  strength 
is  not  known.  But  baths  and  gymnastics  we  know,  by  the 
way  they  influence  the  heart,  increase  its  strength,  just  as 
dumb-bell  exercises  increase  the  strength  of  the  muscles  of 
the  arm.  There  are  cases  in  which  drugs  fail,  as,  for 
example,  in  many  forms  of  cardiac  insufficiency  occurring  in 
obese  persons  without  any  anatomical  lesion  of  the  heart,  in 
many  obstinate  dilatations  of  the  right  side  of  the  heart  from 
mitral  stenosis,  and  when  there  are  lingering  remains  of 
overstrain  of  the  heart  or  of  heart-weakness  after  infective 
diseases,  especially  after  articular  rheumatism.  In  the  first 
of  these  gymnastic  exercises  and  in  the  two  last  baths  render 
excellent  service  by  increasing  the  strength  of  the  heart 
which  is  too  weak  to  meet  the  demands  upon  it. 

"Augmentation  of  the  working  capacity  of  these  hearts 


INDICATIONS    FOR   AND   AGAINST  7 

can  often  only  be  effected  by  increasing  their  total  strength. 
As  they  work  they  are  putting  forth  all  their  strength,  but 
that  is  not  sufficient  to  meet  the  demands  upon  them  till  it  is 
proportionately  increased.  Drugs  are  powerless  to  extract 
any  more  work  out  of  these  hearts. 

"In  consequence  of  their  modes  of  action  being  different 
there  is  no  objection  to  prescribing  baths  and  gymnastics  in 
conjunction  with  drugs.  Under  certain  circumstances  the 
latter  put  the  heart  in  a  condition  to  derive  benefit  from  the 
former. 

"  A  further  question,  specially  raised  by  August  Hoffmann, 
is  whether  the  results  of  the  physical  methods  of  treatment 
are  lasting.  Objective  statistics  on  the  point  are  certainly 
very  desirable  but  beset  with  many  difficulties.  It  is  always 
somewhat  uncertain  to  judge  from  subjective  impressions. 
As  far  as  that  is  possible,  I  can  say  from  my  own  experience 
that  very  satisfactory  results  can  be  obtained  in  this  respect 
when  they  are  used  in  the  restricted  manner  just  indicated. 

"  I  need  hardly  mention  that  all  measures  taken  to 
strengthen  the  heart,  such  as  drugs,  baths,  and  gymnastics, 
can  only  be  employed  with  prospect  of  success  if  its  ordinary 
work  be  lightened.  This  applies  especially  to  physical 
methods  which  make  increased  demands  on  the  strength  of 
the  heart  and  work  directly  in  that  way.  These  demands 
may  so  easily  augment  the  ordinary  work  of  the  heart  that  the 
result  may  not  be  the  hoped-for  improvement,  but  in  certain 
circumstances  direct  injury  to  its  strength  by  overstrain. 
When  drugs  are  given  it  is  the  general  rule,  and  very 
rightly  so,  to  curtail  the  patient's  work  or  to  order  complete 
rest.  By  so  doing  the  drugs  make  no  increased  demands  on 
the  work  of  the  heart,  they  only  make  more  of  its  strength 
active  and  its  work  improves  with  this  increase  of  strength. 
But  it  happens  daily  that  patients  with  heart  disease  are 
ordered  carbonic-acid  baths,  gymnastics,  or  even  the  Terrain 
cure  without  reducing  their  ordinary  duties.  That  is  very 
undesirable. 

"  To  carry  out  these  methods  properly  the  patient  requires 
more  rest  than  he  had  formerly.  The  actual  amount  of  rest 


8      GYMNASTICS   FOR    HEART   AFFECTIONS 

that  should  be  taken  depends  on  the  condition  of  the  patient. 
Precise  rules  regarding  it  cannot  be  laid  down,  but  it  is 
always  better  to  order  too  much  than  to  run  the  risk  of  over- 
straining the  heart.  The  necessity  of  resting  the  heart 
holds  good  in  ordering  all  therapeutic  measures.  For  this 
reason  baths  and  gymnastics  should  not  be  prescribed 
together  till  it  is  certain  that  the  heart  will  react  to  the 
additional  demand  on  it  in  the  manner  desired.  After  each 
bath  and  each  gymnastic  practice  the  patient  must  take 
ample  rest.  It  is  necessary  to  be  specially  stringent  in 
ordering  rest  after  overstrain  and  to  persons  suffering  from 
the  results  of  overstrain.  More  or  less  extensive  reduction 
of  the  ordinary  occupation  must  likewise  be  made  in  cases 
of  obesity  with  heart  insufficiency.  Reduction  of  bodily 
weight  is  better  effected  by  dietetic  measures.  In  obesity, 
moreover,  it  not  infrequently  happens  that  with  greater  rest, 
and  in  certain  circumstances  with  richer  diet  than  formerly, 
the  patient  to  his  surprise  loses  weight,  sometimes  very 
rapidly,  as  the  stronger  action  of  the  heart  causes  excretion 
to  take  place  of  the  surplus  water  previously  retained  in  the 
body,  which  in  obesity  may  reach  a  very  significant  amount 
without  causing  oedema." 


CHAPTER    III 

Medical  Supervision  Necessary — Methods  of  Controlling  the  Effects  of 
Gymnastics  on  the  Patient — Observations  on  the  Pulse. 

THE  principal  thing  in  a  gymnastic  cure  is  the  instruction 
of  the  person  who  has  to  do  the  gymnastics.  It  should 
at  once  be  said  that  at  the  beginning  of  a  gymnastic  cure 
medical  supervision  is  absolutely  necessary  in  affections  of 
the  heart.  It  is  only  when  a  certain  stage  is  reached  and 
the  patient  can  go  through  certain  gymnastic  tasks  without 
any  effort  that  he  can  dispense  with  medical  supervision. 
Even  then  it  is  always  necessary  for  him  now  and  again  to 
see  his  physician,  so  that  the  latter  may  determine  whether 
the  gymnastic  exercises  which  he  is  taking  are  suitable  for 
him,  and  modify  them  if  necessary  from  actual  examination 
of  the  patient.  In  testing  the  effects  of  gymnastics  from 
the  physician's  point  of  view,  the  subjective  symptoms  of 
the  patient  play  an  important  part,  and  the  patient  who  is 
expecting  much  from  gymnastics  may  deceive  himself  by 
his  hopefulness,  especially  at  first.  There  are  some  persons 
who  are  so  hardy  that  they  are  hardly  ever  conscious  of 
slight  variations  in  their  state  of  health.  Others  again,  and 
these  are  the  more  numerous,  are  of  a  more  nervous  dis- 
position, and.  in  their  anxiety  about  their  condition  often 
imagine  themselves  to  be  worse  when  they  are  not.  With  the 
former  the  physician  must  be  cautious  and  reserved,  as  they 
are  too  ready  to  say  to  him,  "Give  me  something  more  to 
do,  I  can  bear  it."  These  patients  are  not  always  the  least 
affected,  and  are  often  dominated  by  an  incredible  optimism 
which  might  very  easily  induce  the  unwary  observer  to  do 

9 


io     GYMNASTICS    FOR    HEART   AFFECTIONS 

too  much,  and  in  this  way  harm  to  the  patient  might  arise. 
The  latter,  namely,  the  anxious,  he  must  deal  with  often  in 
an  entirely  different  manner,  and  show  them,  by  objective 
demonstrations,  what  they  can  do  without  injuring  them- 
selves, so  as  to  encourage  them  to  attempt  exercises  which 
make  greater  demands  on  their  strength,  but  are,  in  his 
judgment,  within  their  capacity.  At  the  same  time  the 
physician  must  be  careful  not  to  make  the  optimists 
pessimists,  and  the  anxious  indiscreet.  In  describing  ob- 
jective symptoms  it  is  always  best  to  tell  every  patient  who 
is  curable  the  absolute  truth.  The  manner  in  which  the 
information  is  to  be  imparted  to  him  is,  naturally,  a  matter 
of  judgment  and  tact. 

For  observing  the  actual  effects  of  gymnastics  different 
methods  are  now  available,  by  the  combined  use  of  which 
it  is  possible  to  get  a  clear  indication  of  their  action.  The 
readiest  means  of  testing  whether  gymnastics  are  producing 
any  change  in  the  action  of  the  patient's  heart  are  naturally 
observations  on  the  pulse.  Exertion  causes  changes  in  the 
pulse  even  in  health.  Exercises  therefore  which  have  been 
prescribed  for  a  patient  should  not  be  at  once  discarded 
merely  because  they  increase  the  rapidity  of  his  pulse  ;  but 
after  the  exercises  are  over  it  should  fall  very  quickly  to 
normal.  If  the  increased  rapidity  of  the  pulse  continues 
for  some  time  after  the  exercises,  it  should  undoubtedly  be 
regarded  as  an  unfavourable  symptom  of  the  gymnastics. 
The  first  criterion  therefore  is :  if  after  the  gymnastic 
exercises  the  frequency  of  the  pulse  is  relatively  increased 
beyond  what  it  was  before  the  exercises,  and  if  after  a  short 
rest  it  does  not  return  to  normal,  the  sign  is  unfavourable. 
Of  course  excessive  increase  of  the  pulse-frequency  should 
never  occur  after  the  exercises  ;  thus  a  pulse  of  80  per 
minute  before  the  exercises  should  not  reach  130  or  140 
after  them.  That  would  indicate  too  much  had  been  done. 
The  proper  ratio  is  shown  in  the  three  pulse-photograms, 


OQ 


OBSERVATIONS   ON   THE    PULSE  13 

Figs.  A,  B,  and  C.1  These  were  taken  from  a  patient  in 
whom  a  severe  attack  of  endocarditis  following  influenza 
had  left  great  weakness  of  the  heart.  Under  careful  treat- 
ment the  patient  improved  so  much  that  his  pulse  showed 
the  results  indicated  in  the  illustrations.  The  first  pulse- 
photogram  (Fig.  A)  was  taken  before  the  gymnastic  exer- 
cises, the  second  (Fig.  B)  immediately  after  them,  and  the 
third  (Fig.  C)  after  the  exercises  when  the  patient  had  rested 
for  ten  minutes  on  a  couch.  Above  the  pulse-curve  is  a  white 
line,  with  small  notches  at  intervals  on  its  upper  surface. 
The  distance  from  one  notch  to  the  other  represents  an 
interval  of  five  seconds  of  time.  The  first  two  figures  show 
that  the  pulse  has  been  scarcely  altered  by  the  gymnastics, 
and  Fig.  C  shows  a  remarkably  steady  pulse.  The  patient 
always  felt  fresh  and  well  after  going  through  all  our 
self-resistance  gymnastics,  and  even  maintained  that  these 
exercises  revived  him  when  he  felt  languid.  Two  other 
pulse-tracings,  Figs.  D  and  E,  show  how  a  pulse  of  irregular 
and  intermittent  character,  as  seen  in  Fig.  D,  has  changed 
till  it  gave  the  pulse-curve  of  regular  outline  shown  in 
Fig.  E.  In  addition  to  having  valvular  disease,  this 
patient  also  suffered  to  a  slight  extent  from  weakness  of 
the  muscular  walls  of  the  heart.  After  food  he  very  often 
complained  of  a  feeling  of  weight  in  the  gastric  and  cardiac 
regions,  and  had  an  intermittent  pulse.  On  several  occa- 
sions it  was  found  that  flatulent  distension  of  the  stomach 
occurred  generally  between  half  and  three-quarters  of  an 
hour  after  meals.  Radiographs  taken  under  these  con- 
ditions frequently  showed  the  diaphragm  to  be  in  an 
elevated  position.  At  first  massage  of  the  stomach  was 
used  with  success  for  the  flatulency.  After  the  massage 
the  pulse-tracing  ceased  to  be  intermittent.  At  a  later 
period  the  same  result  was  obtained  from  gymnastics.-  The 

1    Verhandlungen  des  Congresses  fiir  innern  Medizin,  1907,  p.  561. 
-  "  Pulsaussetzen  und  Ma^enblahung-en. "     Dr.  Med.  J.  Hofmann.      Wiener 
Kleinc  Wochettschrift,  1907,  Nr.  34. 


i4    GYMNASTICS    FOR    HEART   AFFECTIONS 

pulse-tracings  figured  were  taken  before  and  after  gym- 
nastics with  resistance.  Here  then  was  a  case  where  the 
alterations  in  the  heart  were  entirely  due  to  encroachment 
on  its  area  through  the  diaphragm  being  forced  upwards  by 
gastric  distension.  Naturally  it  would  have  been  bad  had 
a  reverse  result  been  recorded  in  the  pulse-tracings.  The 
occurrence  after  the  gymnastics  of  arhythmia,  which  did  not 
previously  exist,  should  make  us  stop  the  exercises  at  once  or 
defer  them  to  a  later  period  ;  or,  if  it  had  been  set  up  by  the 
greater  demands  of  newly  added  exercises,  to  revert  to  the 
previous  ones  requiring  less  effort. 

The  pulse  should  not,  however,  become  too  slow  after 
gymnastics.  When  the  pulse  is  quick  it  is  undoubtedly 
a  good  sign  if  in  a  short  time  after  the  gymnastics  it  falls 
below  what  it  was  before  beginning  them.  As,  for  example, 
when  a  pulse  of  120  per  minute  rises  during  the  gymnastics 
to  130,  and  during  the  period  of  rest  after  them  falls  to  90 
quiet  beats.  That  this  is  a  favourable  sign  will  also  be 
indicated  by  the  subjective  feelings  of  the  patient.  On  the 
other  hand,  it  should  be  regarded  as  a  direct  sign  that  gym- 
nastics are  producing  an  evil  effect  on  the  action  of  the  heart 
when,  for  example,  a  pulse  of  80  per  minute  slows  down  20 
or  30  beats  during  the  rest  after  the  gymnastics.  If  in  brady- 
cardia,  with  a  pulse  varying  from  50  to  60  per  minute, 
gymnastics  have  the  effect  of  still  further  lowering  the  rate 
of  the  pulse,  they  must  be  stopped  at  once.  A  pulse  which 
is  usually  too  slow  should  become  quicker  after  gymnastic 
exercises  or  after  a  series  of  such  exercises,  but  never  slower, 
while  they  should  lower  the  rate  of  a  quick  pulse.  If  gym- 
nastics do  not  produce  the  results  just  mentioned  in  each  of 
these  conditions,  then  they  are  not  suitable  for  the  patient. 

We  must  now  briefly  consider  the  influence  of  gymnastics 
on  the  irregular  pulse.  We  have  often  observed  that  an 
irregular  pulse  does  not  become  regular,  although  the 
patient  may  assure  us  that  the  gymnastics  are  having  a  very 


MEDICAL   SUPERVISION   NECESSARY        17 

favourable  influence  on  his  subjective  sensations  and  condi- 
tion. Here  we  are  confronted  with  the  want  of  a  proper  test 
to  show  us  by  the  feel  of  the  pulse  the  effects  of  gymnastics. 
Certainly  with  the  finger  we  can,  by  practice,  determine 
whether  a  pulse  has  become  stronger  and  whether  from 
being  hard  it  has  become  soft,  which  would  be  good  signs  ; 
and  with  the  finger  we  can  also  detect  bad  signs,  such  as  a 
change  from  a  full  and  strong  pulse  to  a  weak  and  thread- 
like one.  But,  in  the  case  of  a  very  irregular  pulse,  palpa- 
tion fails  to  help  us  to  arrive  at  a  discriminative  judgment. 
We  have  therefore  to  employ  another  method,  which  is  so 
important  that  we  cannot  dispense  with  it  even  in  patients 
whose  pulses  are  not  irregular,  namely  observation  of  the 
blood-pressure. 


CHAPTER   IV 

Testing  the  Effects  of  Gymnastics  by  Observations  on  Blood-pressure, 
Auscultation,  Percussion,  Rontgcn  Rays. 

IN  making  researches  on  blood-pressure  after  gymnastic 
exercises,  we  must  always  take  care  that  the  controls  are 
made  under  similar  external  conditions  ;  this  applies  also  to 
observations  on  the  pulse.  We  proceed  thus  : — After  a 
short  rest  in  the  horizontal  position  the  blood-pressure  is 
determined  by  Riva-Rocci's  method  before  the  exercises. 
Certain  definite  work  is  then  done,  and  immediately  after- 
wards the  blood-pressure  is  tested  in  a  resting  position  as 
before.  The  patient  then  does  some  more  exercises,  and  at 
short  intervals  the  blood-pressure  is  tested  till  the  same 
pressure  is  shown  as  obtained  before  the  gymnastics  were 
begun.  Great  care  must  be  taken  that  the  Riva-Rocci 
manchette,  or  preferably  the  broad  modification  of  it  by 
Recklinghausen,  is  always  applied  in  the  same  way,  so  as  to 
eliminate  as  far  as  possible  errors  of  variation.  It  must 
always  be  of  the  same  breadth  and  be  put  on  the  same  part 
of  the  upper  arm  ;  it  is  also  desirable  to  have  a  centimetre 
scale  marked  upon  it  so  as  to  facilitate  its  being  drawn  in  to 
the  same  point  each  time.  After  a  definite  amount  of  work 
has  been  done  the  blood-pressure  will  show  one  or  other  of 
the  following  possible  conditions  :— 

1.  The  blood-pressure  may  remain  unaltered. 

2.  The  blood-pressure  may  first  rise  and  then  fall  to  the 
normal.1 

3.  The  blood-pressure  may  first  fall  and  then  rise  to  the 
normal. 

1  The  normal  is  regarded  here  as  the  blood-pressure  before  any  work  has 
been  done. 

18 


TESTING   THE   EFFECTS  19 

4.  The  increased  blood-pressure  may  fall  below  the  normal 
before  it  returns  to  normal. 

5.  The  lowered  blood-pressure  may  rise  above  the  normal 
before  it  returns  to  normal. 

6.  The  increased  blood-pressure  may  sink  below  and  never 
reach  the  normal. 

7.  The   lowered    blood-pressure  may    remain    under   the 
normal. 

8.  The  lowered  blood-pressure  may  rise  above  the  normal 
and  remain  so. 

9.  The  increased  blood-pressure  may  remain  above  the 
normal. 

The  time  during  which  these  variations  of  the  blood- 
pressure  should  be  observed  is,  in  our  opinion,  ten 
minutes. 

If  the  blood-pressure  does  not  alter  (i),  then  we  may 
rightly  conclude  that  the  exercises  are  doing  the  patient  no 
harm,  and  that  they  may  be  continued  and  increased. 

(2)  If  the  blood-pressure  is  raised  it  is  not  a  bad  sign  if 
the  rise  be  not  too  sudden.      Even  in  healthy  hearts  we  find 
the  blood-pressure  increased  with  exercise,  but  afterwards  it 
falls  very  rapidly  to  normal.       This  is  an  important  point  in 
all  cases  of  increased  blood-pressure.      A  moderate  rise  and 
a  quick  return  to  the  normal  are  favourable  signs. 

(3)  A    lower   blood-pressure  after   gymnastic   work   than 
before  it  is  not  necessarily  a  bad  sign,  provided  the  blood- 
pressure  again  rises  quickly  to  the  normal  during  rest.       A 
fall  in  the  blood-pressure  after  severe  exercise  may  also  be 
observed  in  healthy  persons,  and  is  brought  about  by  the 
action    of  the    nervus   depressor  causing   dilatation    of  the 
cutaneous  blood  vessels,  and  so  regulating  the  flow  of  blood 
from  the  aorta  where  the  pressure  is  highest.     But  soon  after 
exercise   the    blood-pressure    rises    again    to    the    normal, 
because    during    rest    the    increased   activity  of   the    heart 
diminishes  very  rapidly,  the  high  blood-pressure  in  the  aorta 


20    GYMNASTICS   FOR   HEART   AFFECTIONS 

drops,  and  simultaneously  the  action  of  the  nervus  depressor1 
which  has  caused  the  dilatation  of  the  cutaneous  vascular 
system  ceases. /Thereupon  the  latter  immediately  contracts, 
the  transverse  diameter  of  the  blood  vessels  becomes  smaller 
and  the  blood-pressure  rises  and  may,  without  any  bad 
results,  even  exceed  the  normal  for  a  short  time  (5).  It  is 
different,  however,  if  during  rest  after  exercise  the  blood- 
pressure  remains  for  a  long  time  below  the  normal.  Then 
we  have  feeble  working  as  a  result  of  fatigue  occurring  in  a 
weak  heart.  When  the  blood-pressure  rises  after  exercises 
and  remains  above  normal  (8), we  recognise  in  this  continued 
secondary  elevation  of  the  blood-pressure  Moritz's  symptom 
of  "strain  and  exhaustion  "  which  indicates  that  too  much  has 
been  done.  We  must  also  regard  as  a  sign  of  strain  and 
exhaustion  the  fall  to  below  the  normal  of  a  blood-pressure 
which  has  risen  to  above  the  normal  (4),  and  by  the  amount 
of  rise,  the  extent  of  the  fall,  and  the  time  taken  to  return  to 
the  normal,  we  form  an  estimate  of  the  unfavourable  effect 
and  overstrain  which  has  resulted  from  doing  too  much. 
Finally,  if  the  blood-pressure  rises  too  violently  and  remains 
for  a  long  time  above  the  normal  (9),  it  indicates  overstrain, 
after  which  we  must  always  fear  the  effect  of  exhaustion. 

Examination  of  the  heart  by  means  of  auscultation  and 
percussion,  and  also  by  X-rays,  should  not  be  omitted 
whether  the  results  of  gymnastics  as  shown  by  the  pulse  and 
blood-pressure  are  good  or  bad.  Regarding  percussion,  we 
often  find  when  the  pulse  and  blood-pressure  show  unfavour- 
able signs  after  gymnastics,  that  the  area  of  heart  dulness  is 
broader  than  it  was  previously;  while,  on  the  other  hand,  an 
orthodiagram  shows  no  alteration  in  the  shadow  of  the  heart. 
It  was  this  broadening  which  in  former  times  frequently  led 
physicians'  to  diagnose  acute  dilatation  of  the  heart.  Fortun- 
ately that  is  not  the  case,  or  it  would  be  very  serious,  as 

1  According  to  Koster  and  Tscherm;ik,  the  nervus  depressor  ends  in  I  he- 
aorta  it>elf. 


TESTING   THE   EFFECTS  21 

August  Hoffmann  was  quite  right  in  the  assertion  which  he 
made  at  the  Congress  fur  innern  Medizin  in  1902,  that  acute 
dilatation  is  the  most  dangerous  affection  of  the  muscle  of 
the  heart.  In  this  instance  it  is  what  may  be  called  deceptive 
dilatation  of  the  heart,  and  is  produced  by  the  heart  working 
in  an  excited  manner  and  giving  off  longer  acoustic  waves. 
In  any  case,  this  deceptive  dilatation — that  is  to  say,  the 
sudden  appearance  of  a  divergence  between  the  optical  (ortho- 
diagram)  and  the  acoustic  (percussion)  outlines  is  a  warning 
that  we  must  be  cautious  in  prescribing  work.  Their  coinci- 
dence again  is  indicated  by  simultaneous  improvement  of  the 
pulse  and  blood-pressure.  We  may  be  sure  that  in  the 
majority  of  cases  the  heart  which  shows  this  very  irritable 
type  of  action  (v.  Criegern)  will  also  show  marked  modifi- 
cations in  the  blood-pressure  of  the  character  of  (9)  (strain 
according  to  Moritz).  As  it  returns  to  normal,  the  acoustic 
outline  also  returns  to  that  of  the  orthodiagram.  We  find 
this  phenomenon  very  frequently  in  neurasthenics  suffering 
from  heart  affection.  A  suitable  course  of  gymnastics, 
especially  in  conjunction  with  a  course  of  baths,  causes  it  to 
disappear.  In  these  cases,  when  the  action  of  the  heart  is 
turbulent,  the  more  the  acoustic  outline  approaches  the 
optical,  so  much  the  better  will  be  the  condition  of  the 
blood-pressure  and  of  the  pulse,  and  so  much  the  more  will 
the  patient  be  sensible  of  the  improvement  which  has  taken 
place  in  the  state  of  his  health. 

But,  on  the  other  hand,  by  more  minute  observation  we 
may  be  able,  after  severe  gymnastic  exercises,  when  the  state 
of  the  blood-pressure  and  of  the  pulse  is  not  favourable,  to 
ascertain  from  radiographs  that  the  heart  is  smaller  than 
formerly.  In  that  case  we  may  have  to  do  with  overloading 
of  the  greater  circulation.  Here  an  examination  of  the 
blood-pressure  will  assist  us  in  testing  whether  the  de- 
crease of  the  heart's  shadow  is  to  be  regarded  as  favourable 
or  not.  The  result  obtained  usually  corresponds  to  varia- 


22     GYMNASTICS   FOR   HEART  AFFECTIONS 

tions  (3)  and  (5),  and  in  the  most  unfavourable  cases  to 
variation  (7). 

This  unfavourable  reduction  of  the  silhouette  of  the  heart, 
which,  according  to  Kraus,  is  due  to  imperfect  filling  of  its 
cavities,  is  not  a  satisfactory  sign.  It  arises  through  func- 
tional weakness  of  the  heart  which  is  not  strong  enough  to 
carry  on  properly  the  flow  of  blood  in  the  greater  circulation. 
Equally  unfavourable  is  enlargement  of  the  heart,  which, 
especially  when  the  walls  of  the  right  ventricle  are  weak,  is 
produced  by  its  strength  not  being  sufficient  to  carry  on 
effectively  the  lesser  circulation  through  the  lungs.  We  also 
find  in  the  bad  results  shown  by  the  blood-pressure  (falling 
below  and  remaining  under  the  normal)  confirmatory 
evidence  of  an  unfavourable  nature.  In  these  cases  baths 
(especially  alternating  current  baths),  in  conjunction  with 
carefully  conducted  gymnastics,  act  very  beneficially — much 
better  and  more  energetically  than  CO.,  baths.  In  cases 
where  we  have  only  to  deal  with  irritable  action,  the  strong 
stimulus  of  the  alternating  current  increases  the  irritable 
condition.  Oxygen  baths  and  weak  CO.,  baths  should,  on 
account  of  their  soothing  effect,  be  given  in  such  cases.  It 
must  not  be  forgotten,  also,  that  hydrotherapy  acts  often 
in  a  marvellous  manner  in  consequence  of  the  stimulating 
effects  of  temperature.  The  object  of  employing  these 
various  means  of  relief  is  to  overcome  the  resistance  of  the 
muscular  coats  of  the  vessels.  Graupner  has,  as  far  back  as 
1896,  rightly  laid  stress  on  this  being  the  principal  effect  of 
the  Nauheim  baths.  Absolute  increase  of  the  work  of  the 
heart,  such  as  can  be  obtained  by  the  action  of  digitalis  (and 
as  we  can  also  get  by  means  of  suitable  gymnastics),  cannot 
be  obtained  by  baths. 


CHAPTER  V 

Testing-  the  Influence  of  Gymnastics  by  Sommer's  Analysis  of 
Movements — Observations  on  Respiration. 

T^ESIDES  the  means  of  investigating  and  controlling 
-D  the  influence  of  gymnastics  just  discussed,  we  have 
been  trying  another  method,  which  is  very  sensitive  in  show- 
ing the  slightest  sign  of  fatigue.  It  is  still  very  new,  and 
requires  to  be  tested  much  more  extensively.  But  from 
the  experience  we  have  had  of  it  we  consider  it  very  useful, 
and  should  not  like  now  to  do  without  it.  It  consists  in 
testing  fatigue  by  means  of  Sommer's  Analysis  of  the  ex- 
pression of  motion.1 

Every  trembling  movement  of  the  extremity  is  divisible 
into  three  phases  :  a  movement  from  before  backwards  and 
vice  versa,  a  movement  to  the  side,  and  a  movement  from 
below  upwards  and  vice  versa.  By  means  of  an  ingenious 
apparatus  Sommer  has  succeeded  in  splitting  up  and  register- 
ing graphically  any  trembling  movements  which  may  occur 
unconsciously  and  uninfluenced  by  the  will  of  the  person 
under  observation,  into  the  three  above-mentioned  com- 
ponent parts.  If  when  a  person  comfortably  seated  holds 
out  his  leg  in  an  extended  position  there  be  no  trembling 
movement  present,  three  straight  lines  will  be  registered  on 
a  revolving  cylinder  covered  with  blackened  paper  (Figs.  F 
and  H) ;  but  if  there  be  any  trembling  motion,  the  upper  line 
will  show  the  trembling  motion  from  below  upwards,  and 
from  above  downwards,  the  middle  line  will  show  the  side 
movements,  and  the  lowest  line  those  from  before  backwards 

1  Psychopathologische  Untersuchungsmethoden  v.  A.  Robert  Sommers, 
Prof.  Dr.  Med.  u  Phil.,  Urban  und  Schwarzenberg. 

23 


24    GYMNASTICS   FOR   HEART  AFFECTIONS 

and  the  reverse.  In  Figs.  F  and  H  are  shown  tracings  of 
a  leg  held  perfectly  still,  and  in  Fig.  I  a  violent  tremor  is 
depicted.  In  our  experiments  we  always  used  the  leg,  and 
tested  the  same  limb  always  before  and  after  exercise  in 
the  following  manner.  The  patient  having  seated  himself 
comfortably  on  a  chair  was  told  to  extend  his  leg,  which  was 
supported  while  round  the  ankle  was  being  placed  a 
manchette  connected  by  means  of  a  rod  to  the  writing 
works  of  the  instrument  in  such  a  way  that  the  slightest 
movement  of  the  leg  was  directly  transmitted  to  it, 
and  the  jerks  corresponding  to  the  three  phases  registered. 
After  the  manchette  was  fixed,  the  patient  was  told  to 
hold  out  his  leg  unsupported  and  keep  it  quietly  but 
not  too  rigidly  extended,  and  to  shut  his  eyes.  The 
cylinder  was  then  made  to  rotate,  and  on  the  smoked 
paper  round  it  were  recorded  three  more  or  less  regular  lines 
showing  the  absence  of  tremor  or  its  presence  in  a  stronger 
or  feebler  degree  in  the  limb.  From  the  four  tracings 
figured  it  will  be  seen  that  there  is  no  difference  between 
Fig.  F,  taken  before,  and  Fig.  G,  taken  after  resisted  gymnas- 
tics ;  whereas  there  is  a  marked  difference  between  Figs.  H  and 
I,  also  taken  before  and  after  resisted  gymnastics.  The 
latter  figure  shows  the  tracings  of  great  fatigue.1 

The  theory  of  this  control  is  based  on  the  fact  that  the 
person  whose  muscle  is  tired  is  not  able  to  hold  his  leg  out 
straight  with  the  same  ease  as  when  his  muscles  are  not 
fatigued.  He  must  exert  himself  when  he  is  tired  to 
do  the  same  thing  that  he  could  do,  when  fresh,  without 
fatigue  or  strain.  The  strain  of  the  muscular  system — that 
is  to  say,  the  energetic  contractions  of  the  quadriceps— is 
indicated  by  more  or  less  strongly  marked  tremulous  move- 
ments. It  is  an  excellent  illustration  of  Moritz's  "will- 
strain  and  fatigue"  shown  unconsciously  by  a  tired  patient. 

1  Fig.  I  was  taken  intentionally  when  the  limb  was  very  tremulous  for  tin- 
urpose  of  demonstrating  the  tremors  clearly. 


SlAieflORMALSCHUUi, 

,  CKttt. 


TESTING   THE    INFLUENCE  27 

In  this  control  the  nature  of  the  variations  in  the  three  com- 
ponent curves  informs  us  whether  or  not  too  much  has  been 
done  by  the  patient.  The  results  given  by  the  pulse  and 
blood-pressure  may  be  confirmed  or  differentiated  by  this 
method.  Thus,  if  after  gymnastics  the  result  of  an  examina- 
tion of  the  blood-pressure  is  unsatisfactory  while  that  of  the 
analysis  of  the  expression  of  motion  is  good,  we  may  be 
sure  that  the  blood-pressure  and  the  pulse  will  soon  change 
for  the  better. 

At  the  Congress  fiir  innern  Medizin,  1907,  F.  Klemperer 
laid  stress  on  the  fact  that  he  has  found  all  the  curves,  i.e., 
Graupner's  Pathognostic  blood-pressure  curves,  in  healthy 
persons  as  well  as  in  invalids.  We  can  also  confirm  the 
statement  that  blood-pressure  curves,  apparently  morbid,  are 
frequently  obtained  from  healthy  persons.  But  stress  must 
be  laid  again  on  the  fact  that  one  method  of  investigation 
only  is  not  sufficient  for  all  requirements.  If  by  different 
methods  of  research  (as,  for  example,  those  already  men- 
tioned) we  find  pathological  conditions  or  deviations  from 
the  normal  present  in  each  instance,  then  we  are  fully 
justified  in  speaking  of  them  as  morbid  conditions,  as  we 
have  then  a  criterion  to  go  by.  It  is  only  by  taking  into 
account  the  several  results  derived  from  different  researches 
by  different  methods  that  we  can  obtain  sufficient  information. 
Thus  by  auscultation  of  the  heart  we  can  discover  with 
certainty  valvular  defects.  But  it  is  from  the  blood-pressure, 
the  pulse,  the  orthodiagram,  functional  examination  (for 
example,  by  Rumpf's  method),  examination  of  the  liver, 
urine,  lungs,  etc.,  that  we  discover  whether  or  not  the  valvu- 
lar deficiency  is  compensated  or  the  heart  is  easily  fatigued. 
A  markedly  different  finding  after  a  single  research  by  one 
method  of  investigation  should  not  induce  us  to  form  a 
premature  judgment  of  the  case,  but  should  incite  us  to  try 
all  the  other  methods,  so  as  to  guard  ourselves  as  far  as 
possible  against  the  danger  of  being  deceived.  The  most 


28     GYMNASTICS   FOR    HEART   AFFECTIONS 

painstaking  observation  is  especially  necessary  in  the  medical 
control  of  gymnastics.  It  is  in  this  way  only  that  the 
patient  can  obtain  what  he  expects  of  us,  and  we  ourselves 
will  find  satisfaction  in  our  work. 

In  conclusion,  we  have  still  to  mention  one  very  impor- 
tant kind  of  research,  which  is  also  one  of  the  earliest.  It  is 
observation  of  the  Respiration.  After  the  exercises  it 
should  show  no  unfavourable  symptoms  as  regard  either 
frequency  or  depth.  An  old  practitioner  used  to  make  his 
heart-affected  patients  go  up  a  short  flight  of  stairs,  first 
slowly  and  then  quickly,  to  test  the  action  of  their  hearts. 
Then  from  the  condition  of  the  pulse  and  the  respiration 
after  each  test  he  used  to  draw  his  conclusions,  which  always 
stood  him  in  good  stead.  In  this  way  he  obtained  the  com- 
bined results  of  two  methods  of  investigation,  even  though 
they  were  only  of  the  simplest  and  readiest  kind. 


CHAPTER   VI 

The  Different  Ways  in  which  Gymnastics  may  be  Used — Their  Object 

IN  plates  1-42  are  shown  photographic  reproductions 
of  those  exercises,  which  in  the  opinion  of  the  authors 
are  best  suited  for  the  gymnastic  treatment  of  heart  affec- 
tions. The  exercises  may  be  practised  either  as  4<  passive" 
or  as  "active"  gymnastics.  At  the  outset  it  should  be 
stated  that  exercises  i  to  8,  which  should  be  done  while 
the  patient  is  lying  in  a  recumbent  position,  may  also  be 
used  as  resistance  gymnastics  by  instructing  the  patient  to 
perform  the  movements  against  resistance  offered  by  the 
person  who  is  superintending  the  gymnastics.  As  during 
the  early  stages  of  convalescence  passive  gymnastics  are  in 
the  first  instance  principally  wanted  and  have  to  be  under- 
taken in  the  lying  position,  we  have  preferred  to  illustrate 
them  being  done  in  that  position  and  in  the  passive  form. 
When  the  patient  has  so  far  improved  that  he  can  practise 
the  gymnastics  sitting  or  standing,  passive  gymnastics  are 
only  suitable  for  the  first  few  sets  of  exercises  at  most. 

In  passive  gymnastics  the  patient,  having  assumed  the 
proper  position  for  the  exercise,  relaxes  his  muscles  entirely 
as  in  sleep;  the  superintendent  then  proceeds  to  perform  the 
different  exercises  upon  him  while  he  does  not  exert  his 
muscles  in  any  way.  Thus,  for  example,  the  superintendent 
(designated  H  throughout  the  series  of  exercises)  raises  the 
patient's  leg,  rotates  his  trunk,  etc.,  while  the  patient 
himself  (designated  G  in  the  exercises)  does  absolutely 
nothing.  He  simply  allows  his  arms,  legs,  and  trunk  to 
be  moved  without  his  putting  forth  any  nerve  energy  into 

3' 


32     GYMNASTICS   FOR   HEART  AFFECTIONS 

his  muscles  ;  in  short,  he  is  entirely  passive  as  regards  the 
gymnastics. 

As  the  cure  progresses  the  patient  proceeds  to  active 
gymnastics  with  resistance  ;  that  is,  he  performs  the 
different  exercises  himself  by  innervation  of  his  muscles  ; 
he  bends  his  forearm,  for  example,  instead  of  having  it 
bent  for  him,  while  the  superintendent  resists  his  action 
gently  at  first  but  with  increasing  force. 

We  can  readily  appreciate  how  exceedingly  varied  the 
graduations  may  be  made  in  these  gymnastics  beginning 
with  the  smallest  possible  exertion,  such,  for  example,  as 
is  entailed  in  simply  raising  and  lowering  the  fully  relaxed 
arm  of  a  person  resting  quietly  in  a  horizontal  position,  up 
to  the  strong  resistance  which  can  be  offered  when  the 
exercise  is  performed  by  the  patient. 

The  exercises  require  more  effort  on  the  part  of  the 
patient  when  done  without  the  assistance  of  the  super- 
intendent, and  also  the  more  slowly  they  are  executed. 
The  patient  is  directed  to  bend  the  arm  slowly  and  to 
straighten  it  again,  to  raise  the  leg  slowly  and  then  to 
lower  it,  to  rotate  the  trunk  slowly,  etc.  When  practised 
in  this  way  without  assistance  the  exercises  should  be  per- 
formed by  the  patient  without  straining  his  muscles.  They 
should  also  be  done  as  slowly  as  possible  and  without  strong 
will-power  being  brought  to  bear  upon  the  muscles,  so  that 
muscular  strain  may  be  avoided  as  much  as  possible.  Thus 
performed  the  gymnastics  form  an  intermediate  step  between 
resistance  gymnastics  and  actual  self-resisted  gymnastics, 
though  in  reality  this  is  the  lightest  form  of  self-resisted 
gymnastics,  since  the  patient  must  of  necessity,  in  order 
to  do  the  exercises  as  slowly  as  possible,  permit  a  certain 
amount  of  self-resisting  influence  to  come  into  action. 
These  self-performed  gymnastics  without  resistance  when 
done  slowly  and  without  putting  forth  strained  muscular 
action  have  an  exceedingly  soothing  effect,  especially  in 


THE    DIFFERENT   WAYS  33 

nervous  patients  (neurosis  of  the  heart).  We  have  often 
observed  that  the  severer  form  of  gymnastics  without 
apparatus,  in  which  there  is  strong  innervation  of  the 
muscles  and  strained  muscular  action,  are  badly  borne  by 
neurasthenics,  whereas  this  milder  form  never  fails  to 
produce  its  soothing  action  and  to  effect  improvement  and 
ultimate  cure  in  these  cases. 

The  strain  on  the  patient  is  still  further  increased  when 
he  is  directed  to  apply  to  himself  the  resistance  which  had 
previously  been  offered  by  the  superintendent.  To  do  this 
the  patient  has  to  imagine  that  someone  is  impeding  him 
in  the  performance  of  his  gymnastic  exercises.  He  has, 
for  example,  to  imagine  that  when  bending  his  arm  some- 
one is  resisting  the  movement  by  counter-pressure,  and, 
with  this  thought  fixed  in  his  mind,  to  perform  the 
gymnastic  with  an  effort  proportionate  to  the  resistance 
which  in  his  imagination  is  being  offered.  This  highest 
step  in  our  forms  of  gymnastics  is  termed  self-resisted 
gymnastics  (selbsthemmungs-gymnastik),  as  the  patient 
himself  supplies  the  resisting  force  in  each  gymnastic 
exercise. 

When  practising  this  form  of  gymnastics,  for  which  all 
the  exercises  of  the  series  we  have  arranged  and  illustrated 
are  suitable,  the  supervising  control  of  the  physician  is 
especially  necessary.  Overstrain  can  very  easily  result 
from  them  unless  each  exercise  is  carefully  graduated  to  the 
patient.  One  of  our  greatest  authorities  on  gymnastics, 
Herz  of  Vienna,  who  has  already  been  mentioned,  has  not 
inaptly  employed  this  kind  of  gymnastics  for  testing  the 
functional  efficiency  of  the  heart.  Even  a  healthy  person 
is  easily  tired  if  he  attempts  to  do  several  self-resisted 
gymnastic  exercises  without  previous  practice.  To  deter- 
mine whether  the  patient  is  bringing  into  play  sufficient 
counter-innervation  while  doing  self-resisted  gymnastics  is 
not  a  difficult  matter  for  the  physician.  It  is  more  difficult 


34     GYMNASTICS   FOR   HEART   AFFECTIONS 

for  him  to  determine  whether  the  patient  is  not  over-exerting 
himself  by  putting  forth  too  much  innervation.  Neverthe- 
less he  must  estimate  exactly  the  amount  of  effort  the 
patient  may  be  permitted  to  exert.  To  enable  him  to  do 
this  he  must  during  the  stages  before  self-resisted  gym- 
nastics are  begun — namely,  when  passive  and  active  re- 
sistance gymnastics  are  being  practised — form  a  clear  idea 
in  his  mind  of  what  his  patient  is  able  to  do.  He  must 
now  look  out  even  more  sharply  than  he  did  in  the  earlier 
stages  for  signs  of  approaching  fatigue.  For  this  purpose 
the  use  of  Sommer's  Method,  previously  described,  has 
in  our  hands  rendered  us  excellent  service  when  training 
patients  in  this  form  of  gymnastics. 


CHAPTER   VII 

The  Order  in  which  the  Gymnastics  should  be  practised  and  their  object  — 
Special  exercises — The  Importance  of  Breathing  properly  during  the 
exercises — The  Clothing  during  and  after  exercises — Diet  and  Stimulants. 

WE  have  now  to  discuss  generally  the  question  of  the 
order  in  which  the  exercises  should  follow  one 
another.  In  the  first  instance  simple  passive  gymnastics 
should  be  practised  lying  down,  namely,  the  exercises  i  to  8 
inclusive.  When  these  exercises  can  be  undergone  without 
shosving  any  signs  of  fatigue,  the  patient  can  then  proceed 
to  passive  exercises  in  the  standing  position,  by  adding  to 
the  exercises  in  the  lying  position  some  passive  exercises 
standing.  When  sufficient  progress  has  been  made  so  that 
the  patient  is  able  to  do  all  the  exercises  from  i  to  27 
inclusive,  one  after  the  other,  passively,  without  any  signs  of 
exhaustion,  but  of  course  with  a  short  pause  between  each, 
active-resistance  gymnastics  may  be  begun  in  the  lying 
position,  in  the  first  instance  by  introducing  into  the  exer- 
cises formerly  practised  passively  some  slight  resistance  (as, 
for  example,  by  offering  slight  resistance  while  the  arm  is 
bent  by  the  patient  in  the  lying  position).  Then  gradually 
all  passive  movements  are  replaced  by  resistance  exercises, 
till  the  patient  can  do  these  exercises  one  after  the  other 
without  any  exertion  to  speak  of.  Again,  in  the  same  way  as 
we  proceeded  from  purely  passive  gymnastics  to  resistance 
gymnastics,  we  pass  on  to  self-resistance  gymnastics.  When 
we  have  reached  the  stage  that  the  exercises  can  be  done  by 
the  patient  as  self-resisted  gymnastics  without  showing 
signs  of  fatigue,  the  patient  may/be  permitted  to  do  the 
remainder  of  his  gymnastic  course  without  medical  super- 
vision. But  even  then  the  patient  should,  especially  at  first, 

35 


36     GYMNASTICS    FOR    HEART   AFFECTIONS 

consult  his  medical  attendant  at  least  once  per  week  for  pur- 
poses of  control,  so  that  the  latter  may  satisfy  himself  that 
no  overstrain  has  taken  place  in  the  interval. 

On  an  average  at  least  half  a  minute  will  be  required  for 
each  exercise,  inclusive  of  pauses,  and  after  each  exercise 
a  short  rest  should  be  taken.  It  must  be  remembered  that 
these  gymnastics  are  not  for  the  purpose  of  amusement,  nor 
is  the  object  for  which  they  are  used  to  beat  the  record  in 
acts  of  strength.  Their  sole  object  is  to  enable  the  organism 
to  perform  "certain  work  for  a  given  purpose  with  the  least 
possible  excitement  of  the  heart  and  vascular  system." 
When  we  have  reached  the  stage  that  a  patient  is  able  to 
perform  the  exercises  of  self-resistance  gymnastics  with  the 
strongest  counter-innervation  without  causing  more  than 
very  slight  excitement  of  the  heart  and  vascular  system,  we 
may  be  sure  that  he  will  then  be  in  a  position  to  surmount 
the  physical  exertion  of  his  daily  life-x 

In  the  foregoing  brief  outline  of  our  exercises  we  have 
always  referred  to  those  numbered  i  to  27  only.  Figs.  41 
and  42  show  a  gymnastic  exercise  with  apparatus  by  which 
the  patient  can  practise  trunk-bending  in  the  lying  position. 
Raising  the  trunk  from  the  horizontal  to  the  vertical  position 
is  the  most  exhausting  gymnastic  exercise  which  we  know, 
and  to  reduce  the  exertion  it  entails  we  designed  the 
apparatus  figured.  By  unfastening  one  or  more  of  the 
spiral  springs  which,  by  their  strong  traction,  assist  the 
patient  in  raising  himself,  the  exercise  can  be  made  more 
difficult.  The  object  of  this  exercise  is  chiefly  to  strengthen 
the  muscles  of  the  abdomen.  It  is  only  intended  for  those 
patients  who  are  able  to  do  all  the  self-resistance  exercises 
without  much  exertion.  On  patients  whose  digestion  is  out 
of  order  this  exercise  has  a  very  salutary  effect  ;  it  is,  how- 
ever, quite  apart  from  our  specific  gymnastics.  In  heart 
affections  we  disapprove  of  every  form  of  gymnastic 
exercise  which  favours  the  flow  of  a  strong  current  of  blood 


THE    IMPORTANCE   OF   BREATHING          37 

to  the  head,  and  lay  it  down  as  one  of  the  first  rules  in 
gymnastics  that  the  head  should  always  be  the  highest 
point.  We  therefore  disapprove  of  deep  trunk-bending  in 
the  standing  position,  as  in  it  the  head  is  too  deeply 
depressed  and  congestion  is  favoured.  Exercise  28  takes 
the  place  of  trunk-bending.  In  it  the  head  always  remains 
highest,  as  can  be  easily  seen  in  Figs.  41  and  42.  Finally, 
another  exercise  which  we  have  not  figured,  as  it  is  so 
generally  known,  is  knee-bending.  This  exercise  also  we 
can  only  recommend  for  those  who  have  gone  through  self- 
resistance  gymnastics  with  success ;  for  other  patients  it  is 
too  exhausting.  It  has  a  special  value,  however,  as  in  it  we 
possess  an  excellent  means  of  testing  functional  efficiency. 
A  patient  who,  before  beginning  gymnastics,  shows  signs 
of  fatigue  after  bending  the  knee  once  or  twice  may  at  the 
conclusion  of  a  gymnastic  cure  easily  bend  it  a  dozen  times 
without  our  being  able  objectively  to  detect  any  tiring  effect 
from  the  exercise. 

Breathing  plays  an  exceedingly  important  part  in  gym- 
nastics. The  lightest  form  of  passive  gymnastics  forebodes 
only  too  frequently  a  strain  on  heart  patients.  Every 
muscle  when  working  requires  oxygen,  and  a  supply  of  this 
gas  must  be  provided  for  in  the  most  rational  way  during 
gymnastics.  This  can  be  best  effected  by  introducing 
breathing  pauses  during  the  gymnastics,  and  by  letting  the 
patient  take  deep  respirations  (abdominal  breathing)  as  often 
as  possible,  not  only  during  the  course  of  an  exercise,  but 
also  between  each  exercise.  On  the  other  hand,  we  must 
also  take  care  not  to  make  him  take  deep  breaths  while  he  is 
in  positions  which  are  unsuitable  for  abdominal  breathing. 
Thus  it  would  be  wrong  to  let  a  patient  stop  to  take  a  deep 
breath  during  gymnastic  27,  Fig.  40.  It  is  especially  de- 
sirable that  at  the  conclusion  of  the  gymnastics  task  the 
patient  should  take  twenty  to  thirty  deep  respirations  while 
lying  down  resting. 


;,8     GYMNASTICS    FOR    HEART   AFFECTIONS 

The  clothing  worn  while  the  gymnastics  are  being  practised 
should  be  as  light  as  possible,  the  patient  should  at  least 
take  off  his  coat  and  collar.  The  ideal  condition  under 
which  all  these  exercises  should  be  taken  is  in  as  large  and 
airy  a  room  as  possible.  During  a  gymnastic  cure  this  is 
not  always  possible,  but  when  the  patient  has  finished  his 
cure  under  his  physician  and  is  to  continue  the  exercises 
independently  at  home,  this  condition  should  be  impressed 
upon  him.  Finally,  it  may  be  mentioned  that  after  gym- 
nastic exercises  a  suitable  cool  rub  down  or  a  warm  bath 
which  is  cooled  down  slowly  is  much  to  be  recommended. 
For  cooling  down  the  baths  Hofmann's  cooling  tubes  are 
very  useful,  as  they  reduce  the  heat  of  the  bath  equally  to 
the  desired  temperature  either  rapidly  or  slowly,  whereas 
simply  running  cold  water  into  a  warm  bath  to  cool  it  always 
does  so  unevenly. 

After  gymnastics  the  patient  should  rest  clothed  as  lightly 
as  possible.  If  he  has  perspired  during  the  gymnastics  he 
should  change  his  underclothing  when  finished,  and  should 
not  mind  the  trouble  this  entails ;  for  this  purpose  also 
he  should  always  take  with  him  fresh  linen  when  he  has  to 
go  to  the  physician  for  exercises,  as  it  might  be  dangerous 
for  a  heart  patient  to  go  after  his  exercises  into  the  cold  air 
with  damp  underclothing,  especially  in  winter. 

It  naturally  stands  to  reason  that  the  best  gymnastic  as 
well  as  the  most  careful  use  of  the  best  physical  therapy  will 
be  useless  if  the  invalid  does  not  carry  out  definite  dietetic 
measures.  It  may  often  be  observed  that  even  at  large  and 
famous  health  resorts  the  most  promising  cases  become 
worse,  because  in  the  first  place  the  patients  are  unreason- 
able in  eating  and  drinking,  and  secondly,  because  in  the 
hotels  and  pensions  the  care  necessary  in  feeding  invalids 
with  heart  affection  is  not  taken.  This  is  an  old  indictment 
which,  curiously  enough,  no  one  will  grapple  with.  It  is 
not  merely  by  the  visit  of  the  physician,  by  taking  the  baths 


DIET   AND   STIMULANTS  39 

he  prescribes  and  by  practising  gymnastic  exercises  under 
his  eye,  but  also  by  following  a  definite  mode  of  living  with 
respect  to  eating  and  drinking  that  the  cure  will  be  success- 
fully effected.  We  are  not  fanatical  supporters  of  abstinence 
theories,  and  have  repeatedly  learned  from  experience  that  a 
glass  of  good  wine  does  not  harm  the  patient  but  renews  his 
vital  energy.  In  spite  of  the  risk  of  being  thought  behind 
the  times,  we  nevertheless  entirely  agree  with  the  old  and 
distinguished  authorities  of  the  last  century  in  this  respect. 
We  do  not  wish  to  say  a  single  word  in  favour  of  indulgence 
in  alcohol,  but  recommend  moderation  and  lay  stress  on  the 
fact  that  there  are  certainly  many  cases  where  use  of  alcohol 
must  be  entirely  forbidden.  It  would  be  foolish  to  suddenly 
prescribe  wine  for  a  patient  who  for  years  past  has  not  taken 
a  drop  of  alcoholic  liquor  ;  on  the  other  hand,  it  appears  to 
us  to  be  very  unnecessary,  especially  in  the  case  of  elderly 
gentlemen  who  have  been  accustomed  to  their  glass  of  wine 
for  years,  to  suddenly  insist  upon  their  becoming  total 
abstainers.  We  have  never  seen  any  success  from  such  a 
course,  but  we  recollect  well  an  elderly  gentleman,  who  of 
his  own  free  will  promised  to  abstain  from  alcohol,  and  made 
so  brilliant  a  gymnastic  cure  that  he  described  himself  and 
still  does  as  a  "record  patient";  nevertheless,  after  six  weeks 
of  his  cure;  he  confessed  to  us  that  he  had  drunk  a  glass  of 
red  wine  every  day  at  midday  and  half  a  litre  of  beer  each 
evening,  as  he  had  been  accustomed  to  do  from  his  youth 
upwards.  It  did  no  harm  to  him  then,  nor  does  it  do  so 
now. 

Other  exercises  could  have  been  added  to  the  list  described 
and  figured,  but  those  selected  are,  for  the  most  part,  recog- 
nised as  being  the  best  adapted  for  heart  patients.  The 
field  of  exercises  should  be  better  defined  by  the  elimina- 
tions which  have  been  made. 

In  conclusion  we  must  once  more  repeat  the  warnings  : 
"The  patient  with  heart  disease  must  learn  the  gymnastics 


40     GYMNASTICS    FOR    HEART   AFFECTIONS 

from  the  physician.  All  movements  and  exercises  in 
remedial  gymnastics  must  be  made  slowly.  All  rapid 
movements  (for  instance,  arm-circling)  should  always  be 
avoided." 


DIRECTIONS  FOR  THE  PERFORMANCE 

OF 

THE  GYMNASTIC  EXERCISES 

AND  ILLUSTRATIONS. 


Explanation  of  the  Text. — G  is  used  in  the  Direc- 
tions to  designate  the  patient  who  is  practising  the 
Gymnastics.  H  denotes  the  person  who  super- 
intends the  Exercises  and  aids  in  their  performance. 


44 


45 


No.  1.     Figs.  1  and  2. 

G.  lies  comfortably  on  his  back  on  a  couch,  with  his 
limbs  extended  and  his  muscles  fully  relaxed.  H.  places 
himself  at  one  side  of  the  couch  and  takes  hold  of  G.'s  wrist 
with  his  hand  corresponding  to  it,  while  he  places  his  other 
hand  on  G.'s  shoulder  of  the  same  side  to  fix  it.  H.  now 
bends  G.'s  forearm  slowly  upwards  and  backwards  on  the 
upper  arm.  The  extent  to  which  the  forearm  should  be 
bent  is  personal,  and  depends  upon  the  amount  of  exertion 
G.  may  be  permitted  to  have.  That  amount  being  reached, 
G.  retains  his  arm  for  a  few  seconds  in  the  flexed  position 
and  breathes  deeply.  H.  then  brings  G.'s  arm  slowly  back 
into  its  position  of  rest  at  starting. 

Exercise  of  the  other  arm  then  follows  in  the  same  manner. 


46 


47 


No.  2.     Fig.  3. 

G.  lies  comfortably  on  his  back  on  a  couch  with  his  limbs 
extended  and  his  muscles  fully  relaxed.  H.  places  himself 
at  one  side  of  the  couch  near  the  foot,  and  taking  G.'s  hand 
nearest  to  him  in  his,  moves  slowly  away  from  the  couch 
and  draws  G.'s  arm  outwards  from  the  body.  The  extent 
to  which  the  arm  should  be  moved  is  personal,  and  depends 
upon  the  amount  of  exertion  G.  may  be  permitted  to  have. 
That  limit  being  reached,  G.'s  arm  remains  for  a  few  seconds 
in  the  abducted  position  while  he  breathes  deeply.  H.  then 
brings  the  arm  slowly  back  to  its  original  position. 

Exercise  of  the  other  arm  then  follows  in  the  same  manner. 


49 


No.  3.     Fig.  4. 

G.  lies  comfortably  on  a  couch  with  his  limbs  extended, 
his  feet  close  together,  and  his  muscles  fully  relaxed.  H. 
places  himself  at  the  foot  of  the  couch,  and  taking  a  light 
hold  of  the  points  of  G.'s  toes,  rotates  his  feet  slowly  outwards. 
G.'s  feet  remain  for  a  few  seconds  in  the  position  shown  in 
Fig.  4,  and  H.  then  presses  them  slowly  together  again. 


No.  4.     Fig.  5. 

G.  lies  extended  on  a  couch  with  his  feet  close  together 
and  his  muscles  fully  relaxed.  H.  places  himself  at  the  foot 
of  the  couch,  and  taking  hold  of  G.'s  legs  firmly  above  the 
ankles,  raises  the  limbs  slightly  and  draws  them  slowly 
apart.  In  this  position  (Fig.  5)  they  remain  for  a  few 
seconds,  during  which  G.  breathes  deeply.  H.  then  brings 
the  limbs  slowly  together  again  and  finally  lowers  them  on 
to  the  couch. 


53 


No.  5.     Fig.  6. 

G.  lies  extended  on  a  couch  with  his  feet  close  together  and 
his  muscles  fully  relaxed.  H.  places  himself  on  the  right 
side  and  near  the  foot  of  the  couch,  and,  taking  hold  of  G. 's 
right  foot  by  the  heel  with  his  right  hand,  slowly  raises  the 
leg  and  draws  it  outwards  (i.e.  abducts  it),  moving  himself 
in  the  act  a  little  away  from  the  couch.  The  position  being 
reached  which  is  shown  in  Fig.  6,  H.  takes  hold  of  the 
point  of  the  toe  with  his  left  hand,  and  rotates  it  slightly 
outwards,  then  inwards,  and  finally  back  to  the  vertical 
position.  A  pause  follows,  during  which  G.  takes  a 
deep  breath.  After  that  H.  brings  the  limb  slowly  back 
to  its  original  position  on  the  couch  by  reversing  the 
previous  movements. 

The  other  limb  is  then  exercised,  H.  standing  on  the  left 
side  of  the  couch  and  taking  hold  of  the  ankle  with  his  left 
hand  and  rotating  the  foot  with  his  right  hand. 


54 


57 


No.  6.     Figs.  7  and  8. 

G.  lies  extended  on  a  couch  with  his  feet  together  and  his 
muscles  fully  relaxed.  H.  places  himself  at  the  right  side  of 
the  couch,  which  he  faces,  opposite  the  patient's  knees,  and 
takes  hold  of  the  leg  nearest  to  him  just  above  the  ankle 
with  his  right  hand,  while  he  places  his  other  hand  im- 
mediately above  the  knee-joint.  H.  then  bends  the  limb 
slowly  at  the  hip  and  knee  joints  by  pushing  the  leg  upwards 
till  the  thigh  is  at  a  right  angle  to  the  body  and  the  leg  and 
thigh  form  an  acute  angle  with  one  another.  In  this 
position,  shown  in  Fig.  7,  the  limb  is  allowed  to  remain  for 
two  or  three  seconds,  during  which  G.  takes  a  deep  breath. 
After  that  H.  raises  the  leg  slowly,  and,  by  simultaneously 
pressing  gently  with  the  hand  on  the  knee,  brings  it  into 
line  with  the  thigh,  as  shown  in  Fig.  8  ;  finally  he  lowers 
the  extended  limb  into  its  original  position. 

The  left  limb  is  then  exercised  in  the  same  way. 


59 


No.  7.     Fig.  9. 

G.  lies  extended  on  a  couch  with  his  feet  together  and  his 
muscles  fully  relaxed.  H.  stands  at  his  feet,  which  he  takes 
hold  of  by  the  heels,  and  raises  both  limbs  slowly,  bend- 
ing them  at  the  hip-joints  while  at  the  knees  they  are 
in  an  extended  position,  till  they  form  an  obtuse  angle  with 
the  trunk,  as  is  shown  in  Fig.  9.  In  this  position  they 
remain  for  a  short  time  while  G.  takes  a  deep  breath,  which 
he  should  be  able  to  do  freely  ;  if  any  difficulty  be  experi- 
enced, the  exercise  is  either  unsuitable  for  him,  or  the  limbs 
have  been  bent  too  much  upward  at  the  hip-joint.  In  the 
latter  case  the  exercise  may  be  repeated,  but  not  on  the  same 
day  ;  and  care  should  be  taken  that  the  limbs  are  not  raised 
as  high  as  on  the  previous  occasion,  so  that  the  angle  formed 
by  them  with  the  body  is  more  obtuse.  After  G.  has  taken 
a  deep  breath,  H.  lowers  the  extended  limbs  to  their 
original  position. 


6o 


6i 


No.  8.     Fig  10. 

G.  lies  on  a  couch  with  his  feet  together  and  his  muscles 
fully  relaxed.  H.  stands  at  his  feet,  and  bending  forward 
with  outstretched  hands,  clasps  G.'s  hands,  which  the  latter 
extends  to  him  without  moving  from  the  horizontal  position. 
H.  now  draws  G.  slowly  towards  him  till  G.  is  in  a  half- 
sitting  attitude,  and  then,  without  any  pause,  lets  him 
gradually  sink  backwards  again  into  his  original  position  of 
rest. 


62 


FIG.  1 1 


No.  9.     Fig.  11. 

G.  stands  with  his  feet  together  in  the  military  position  of 
attention,  his  arms  hanging  vertically  from  his  shoulders. 
H.  stands  at  his  right  side,  and  places  his  right  hand  on  G.'s 
wrist  and  his  left  on  G.'s  shoulder.  G.  now  bends  his  fore- 
arm upwards  towards  his  shoulder  without  moving  his 
upper  arm,  which  remains  firmly  pressed  against  his  body, 
the  forearm  only  being  moved  in  this  exercise.  H.  resists 
the  movement  by  counter-pressure  downwards  with  his  right 
hand,  while  with  his  left  he  prevents  the  shoulder  being 
raised  during  the  exercise.  When  the  forearm  has  been 
flexed  to  the  desired  extent,  G.  forthwith  brings  it  slowly 
back  to  the  vertical  position  without  making  any  pause 
between  the  movements.  H.  resists  the  return  movement 
by  counter-pressure,  as  shown  in  Fig.  11. 

Exercise  of  the  left  arm  is  then  proceeded  with  in  the  same 
manner. 


FIG.  12 


No.  10.      Fig.  12. 

G.  stands  with  his  heels  together  in  the  military  position 
of  attention,  and  stretches  one  of  his  arms  horizontally  out- 
wards and  forwards,  the  forearm  being  midway  between 
pronation  and  supination.  He  now  flexes  the  forearm, 
bringing  the  hand  towards  his  face  (Fig.  12).  H.  stands  in 
front  and  to  one  side  of  him  and  resists  the  movement  with 
his  one  hand,  while  the  other  is  placed  on  G.'s  shoulder  so 
as  to  keep  it  fixed  during  the  exercise.  G.  then,  without 
making  any  pause,  slowly  brings  his  arm  again  into  the 
extended  position,  while  H.  resists  the  movement. 

The  other  arm  is  then  exercised  in  the  same  manner. 


66 


FIG.  13 


68 


FIG.   14 


No.  11.     Figs.  13  and  14. 

G.  stands  with  heels  together  in  the  military  position  of 
attention.  He  extends  his  arms  forwards  (Fig.  13).  FL 
takes  hold  of  them  from  below.  G.  now  moves  them 
outwards  (Fig.  14),  whilst  H.  resists  the  movement  by 
exerting  counter-pressure.  In  doing  so  H.  must  advance 
towards  G.  by  short  steps.  The  extent  to  which  G.  may 
expand  his  arms  is  personal,  and  depends  upon  the  amount 
of  exertion  which  it  is  desirable  for  him  to  have.  That 
being  reached,  G.  takes  a  few  deep  breaths.  H.  then  taking 
hold  of  G.'s  extended  arms  above  the  wrists  from  their  inner 
(or  front)  surfaces  offers  resistance,  while  G.  brings  them 
back  to  the  position  at  starting.  During  the  return  move- 
ment H.  must  take  a  few  steps  backwards. 


FIG.  16 


73 


No.  12.     Figs.  15  and  16. 

G.  stands  with  his  heels  together  in  the  military  position 
of  attention.  He  stretches  out  his  arms  in  front  of  him, 
Fig.  15.  H.  takes  a  light  hold  of  his  wrists.  G.  then  raises 
his  extended  arms,  Fig.  16,  to  which  H.  offers  resistance  by 
light  pressure  downwards.  While  resisting  the  movement 
H.  must  advance  a  few  steps  towards  G.  The  height  to 
which  G.  may  raise  his  arms  is  personal,  and  depends  upon 
the  amount  of  exertion  which  it  is  desirable  for  him  to  have. 
That  being  reached,  G.,  without  any  pause  and  without 
breathing  deeply,  brings  his  arms  back  slowly  to  the  position 
they  were  in  at  starting,  whilst  H.  resists  the  movement 
by  counter-pressure  upwards,  Fig.  16.  In  doing  this  H. 
must  take  a  few  steps  backwards. 


74 


FIG.  17 


S1AJBSORMALSCHOOL 

,  OKI;. 


77 


No.  13.     Figs.  17  and  18. 

G.  stands  in  the  military  position  of  attention.  H. 
places  himself  in  front  of  him  and  takes  hold  of  both  his 
arms  above  the  wrists  as  they  hang  by  his  sides,  Fig.  17. 
G.  now  moves  his  arms  outwards  and  upwards,  while  H. 
resists  the  action  by  counter-pressure  downwards.  The 
extent  to  which  G.  should  raise  his  arms  is  personal,  and 
depends  upon  the  amount  of  exertion  which  it  is  advisable 
for  him  to  have.  When  that  has  been  reached,  H.  takes 
hold  of  G.'s  arms  in  the  manner  shown  in  Fig.  18,  and 
by  counter-pressure  upwards  resists  his  action  in  bringing 
them  back  to  the  position  at  starting.  This  exercise  is  per- 
formed without  any  breathing  pause  between  the  upward  and 
downward  movements. 


78 


FIG.   if) 


79 


No.  14.     Fig.  19. 

G.  stands  firmly  in  front  of  H.  and  moves  his  arms  back- 
wards from  the  vertical  position.  H.  resists  the  movement 
by  counter-pressure  from  behind  forwards,  as  is  shown  in  the 
illustration.  The  extent  to  which  G.  should  move  his  arms 
backwards  is  personal,  and  depends  on  the  amount  of  exer- 
tion which  it  is  advisable  for  him  to  have.  That  being 
reached,  G. ,  without  making  any  pause,  brings  his  arms 
back  to  the  position  at  starting,  while  H.  resists  the  move- 
ment by  pulling  them  backwards. 


So 


Si 


No.  15.     Fig.  20. 

G.  stands  with  one  foot  in  advance  of  the  other  and  bends 
both  arms  at  the  elbow  till  they  rest  against  his  chest.  H. 
places  himself  in  front  of  him  and  takes  hold  of  both  his 
wrists.  G.  then  slowly  thrusts  his  arms  forwards  as  if  he 
would  bring  his  hands  towards  H.'s  breast.  H.  resists  the 
movement  by  counter-pressure,  as  seen  in  Fig.  20.  During 
the  return  movement  to  the  position  at  starting  H.  offers 
resistance  by  counter-traction.  Xo  breathing  pause  takes 
place  during  this  exercise. 


82 


FIG.  21 


84 


FIG.  22 


No.  16.     Figs.  21  and  22. 

G.  stands  with  his  feet  somewhat  apart  and  his  arms 
extended  from  his  sides,  in  the  position  shown  in  Fig.  21, 
the  upper  arms  horizontal  and  the  forearms  bent  at  right 
angles  to  them  and  elevated  to  the  vertical,  the  flexor 
surfaces  directed  forwards.  Retaining  his  arms  flexed  at 
right  angles,  he  moves  his  forearms  forwards  and  down- 
wajds  by  rotating  the  humerus  at  the  shoulder-joint.  H. 
stands  in  front  of  G.,  and  taking  hold  of  the  arms  near  the 
wrists  resists  the  movement.  G.  then,  without  pausing,  pro- 
ceeds to  raise  his  forearms  again  to  the  vertical  position, 
while  H.  resists  the  action  (Fig.  22). 

The  arms  may  be  exercised  separately  instead  of  simul- 
taneously. 


86 


FIG.  23 


87 


No.  17.     Fig.  23. 

G.  stands  at  attention  and  extends  one  arm  horizontally 
outwards  from  his  side,  the  hand  being  clenched.  H.  takes 
hold  of  G.'s  clenched  fist  with  both  hands.  G.  rotates  his 
arm  from  the  shoulder-joint  to  the  hand,  first  forwards  and 
then  backwards,  while  H.  resists  the  movements  by  gentle 
counter-pressure,  first  in  one  direction  and  then  in  the 
other,  as  G.  rotates  his  arm  forwards  and  backwards. 

Exercise  of  the  other  arm  follows  after  G.  has  had  a 
breathing  pause. 

[A  considerable  part  of  the  movement  in  this  exercise  is 
pronation  and  supin'ation  of  the  forearm.] 


88 


FIG.  24 


Fir..   2 


No.  18.     Figs.  24  and  25. 

G.  seats  himself  comfortably  on  a  chair  with  his  legs  bent 
at  right  angles  to  the  thighs  in  the  usual  sitting  position. 
H.,  standing  on  one  side  and  bending  forwards  towards  the 
legs,  takes  hold  of  the  one  nearest  to  him,  placing  one  hand 
over  the  front  of  the  ankle,  the  other  hand  across  the  front 
of  the  thigh  (Fig.  24).  G.  straightens  out  his  leg  by  raising 
it  slowly  from  the  vertical  till  it  is  in  line  with  the  thigh. 
H.  resists  the  movement  by  pressing  the  ankle  downwards. 
H.  then  moves  the  fingers  of  his  hand  behind  the  ankle 
(Fig.  25),  and  by  pulling  in  an  upward  direction  causes 
resistance,  while  G.  bends  his  leg  and  brings  it  back  into 
the  position  at  starting.  After  a  short  breathing  pause  the 
other  leg  is  exercised  in  the  same  manner. 


94 


FIG.  27 


95 


No.  19.     Figs.  26  and  27. 

G.  seats  himself  firmly  on  a  chair  with  his  legs  close 
together.  H.  squats  in  front  of  him  and  lays  his  hands  on 
the  outside  of  each  knee  (Fig.  26).  G.,  keeping  his  feet 
firmly  against  one  another,  draws  his  knees  apart,  which  H. 
resists  by  counter-pressure.  The  extent  to  which  G.  should 
separate  his  knees  is  personal,  and  depends  upon  the  amount 
of  exertion  it  is  desirable  for  him  to  have.  H.  then  places 
his  hands  on  the  inner  sides  of  G.'s  outstretched  knees 
(Fig.  27)  and  offers  resistance  by  pressing  outwards  in  each 
direction,  while  G.  brings  his  knees  together  again  to  their 
original  position.  During  the  exercise  G.  must  breathe 
quietly.  \o  breathing  pause  is  permitted  between  the  out- 
ward and  inward  movements  of  the  knees. 


96 


FIG.  28 


97 


No.  20.     Fig.  28. 

G.  stands  erect  with  his  feet  together  and  rests  both  hands 
on  the  back  of  a  chair  placed  in  front  of  him  to  support  him 
during  the  exercise.  H.  places  himself  behind  G.,  and 
stooping  down,  links  one  hand  round  the  leg  to  be  exercised, 
just  above  the  ankle  ;  the  other  hand  he  rests  on  the  back 
of  the  thigh.  G.  slowly  bends  his  leg  at  the  knee,  raising 
it  backwards  and  upwards  without  moving  his  thigh  from 
the  vertical  position,  while  H.  resists  the  movement.  The 
extent  to  which  G.  should  flex  his  leg  is  personal,  and 
depends  on  the  amount  of  exertion  it  is  desirable  for  him  to 
have.  G.  then  slowly  straightens  his  leg  and  brings  it  back 
to  the  position  at  starting.  H.  resists  the  action  by  upward 
traction. 

Exercise  of  the  other  leg  is  then  proceeded  with  in  the 
same  manner. 

[In  doing  this  exercise  there  is  often  a  tendency  to  move 
the  thigh  forwards.  This  can  be  readily  prevented  by 
H.  placing  his  hand  on  the  front  of  the  thigh  just  above 
the  knee  instead  of  on  the  back  of  the  thigh.  To  do 
this  H.  must  place  himself  on  the  outside  of  the  limb 
exercised.] 


98 


FIG.  29 


1OO 


FlO.  30 


101 


No.  21.     Figs.  29  and  30. 

G.  stands  erect  with  his  feet  together  and  rests  both 
hands  on  the  back  of  a  chair  placed  in  front  of  him  to  sup- 
port him  during  the  exercise.  H.  stands  behind  him,  and 
bending  downwards  in  a  stooping  position,  grasps  the  limb 
to  be  exercised  just  above  the  ankle  with  one  hand  held  in 
the  form  of  a  fork  ;  the  other  hand  he  places  above  the 
buttock.  Thereupon  G.,  holding  himself  as  erect  as  possible, 
moves  the  limb  in  the  extended  position  backwards  and 
upwards  from  the  hip,  while  H.  resists  the  movement  (Fig. 
29).  The  extent  to  which  G.  should  move  his  limb  back- 
wards is  personal,  and  depends  on  the  amount  of  exertion  it 
is  desirable  for  him  to  have.  That  limit  being  reached,  H. 
now  places  his  hand,  bent  in  the  form  of  a  hook,  round  the 
front  of  the  leg  immediately  above  the  ankle,  his  other  hand 
remaining  as  before  above  the  buttock  (Fig.  30),  and  offers 
resistance  by  backward  traction  ;  while  G.  brings  back  his 
still  extended  limb  to  the  position  it  was  in  at  starting. 

Exercise  of  the  other  limb  is  then  carried  out  in  the  same 
manner. 


IO2 


Fie..  32 


'05 


No.  22.      Figs.  31  and  32. 

G.  stands  erect  with  his  feet  together  and  places  his  left 
hand  on  the  back  of  a  chair  by  his  side  to  support  him  when 
standing  on  his  left  leg  during  exercise  of  the  right.  H. 
places  himself  to  the  right  and  in  front  of  G.,  and 
stooping  down  grasps  G.'s  right  leg  just  above  the  front  of 
the  ankle  with  the  right  hand  ;  his  left  hand  he  places  on  the 
front  of  G.'s  thigh.  G.  now  raises  his  limb  in  the  extended 
position  forwards  and  upwards  without  moving  his  body 
from  the  erect  position,  while  H.  resists  the  movement  by 
counter-pressure  (Fig.  31).  The  extent  to  which  G.  should 
advance  his  limb  is  personal,  and  depends  on  the  amount 
of  exertion  he  may  be  permitted  to  have.  That  limit  being 
reached,  H.  moves  his  hand  round  the  back  of  the  leg,  as 
shown  in  Fig.  32.  G.  then  brings  his  still  extended  limb 
slowly  back  to  its  position  at  starting.  H.  resists  the  return 
movement  by  traction  forwards. 

After  G.  has  taken  a  few  deep  breaths,  and  H.  has 
reversed  his  own  position  and  that  of  the  chair  (or  G.  has 
reversed  his),  exercise  of  the  left  limb  is  proceeded  with  in 
the  same  manner. 


io6 


io8 


FIG.  34 


109 


No.  23.     Figs.  33  and  34. 

G.  stands  erect  with  his  feet  together  and  places  his  left  hand 
on  the  back  of  a  chair  placed  by  his  side  to  support  him  so  that 
he  may  be  able  to  stand  firmly  on  one  leg  while  the  other  is 
being  exercised.  H.,  standing  on  G.'s  right  side  and  bend- 
ing down,  takes  hold  of  his  right  leg  just  above  the  ankle 
with  the  right  hand,  his  left  being  placed  on  the  outside  of 
G.'s  hip.  G.  now  abducts  his  extended  limb,  raising  it 
slowly  outwards  and  upwards,  while  H.  resists  the  movement 
by  pressing  it  in  the  opposite  direction  (Fig.  33).  The 
extent  to  which  G.  may  abduct  his  limb  is  personal,  and 
depends  on  the  amount  of  exertion  he  is  permitted  to  have. 
H.  having  moved  his  hand  round  to  the  inner  side  of  the 
leg,  G.  begins  the  return  movement  of  bringing  the  limb  to 
the  ground  again,  during  which  H.  offers  resistance  to  the 
downward  progress  of  the  limb  by  traction  in  the  opposite 
direction.  After  exercise  of  the  right  limb  a  breathing 
pause  follows,  and  then  exercise  of  the  left  limb  is  carried 
out  in  the  same  manner. 


I  IO 


35 


1 1 1 


No.  24.     Fig.  35. 

G.  stands  with  his  feet  together  in  the  military  position  of 
attention.  H.  places  himself  in  front  of  G.  and  grasps  him 
by  both  shoulders  (Fig.  35).  G.  twists  the  upper  part  of 
his  body  slowly  round,  first  to  the  right  and  then  to  the 
left,  without  altering  the  position  his  legs  were  in  at  starting. 
H.  resists  the  movement  by  alternate  counter-pressure,  first 
on  the  right  and  then  on  the  left  shoulder.  The  extent 
to  which  G.  should  rotate  his  body  to  the  right  or  to  the 
left  is  personal,  and  depends  on  the  amount  of  exertion 
which  it  is  desirable  for  him  to  have.  During  this  exercise 
there  is  no  breathing  pause  between  the  movements. 


I  12 


I  I 


No.  25.     Fig.  36. 

G.  stands  erect  with  his  feet  together  in  the  military  posi- 
tion of  attention.  H.  stands  behind  him  and  places  his 
right  hand  on  G.'s  right  shoulder,  his  left  being  placed  on 
G.'s  left  hip.  G.  bends  the  upper  part  of  his  body  to  the  left, 
as  seen  in  Fig.  36,  keeping  the  lower  part  of  his  body  as 
straight  as  possible.  Meanwhile  H.  resists  the  movement  by 
pressing  the  shoulder  downwards.  The  distance  G.  should 
bend  to  the  side  is  personal,  and  depends  upon  the  amount  of 
exertion  it  is  desirable  for  him  to  have.  That  being  reached, 
G.,  without  any  pause,  returns  to  the  erect  posture,  while 
H.  resists  the  movement  by  pressure  with  his  left  hand 
against  G.'s  hip.  Bending  to  the  right  is  then  practised  in 
exactly  the  same  manner,  the  position  of  H.'s  hands  being 
reversed  for  it. 

[Resistance  in  this  exercise  is,  in  the  opinion  of  the  Trans- 
lator, best  offered  by  H.  placing  his  left  hand  on  the  external 
surface  of  G.'s  left  upper  arm  near  the  shoulder,  i.e.  upon 
the  deltoid  muscle  of  the  side  to  which  G.  is  going  to  bend, 
the  other  hand  resting  on  G.'s  opposite  hip.  As  G.  bends  to 
the  left  (Fig.  36),  H.  resists  the  movement  by  pressing  the 
left  shoulder  in  the  opposite  direction  with  his  left  hand, 
while  his  right,  pressing  on  G.'s  right  hip,  assists  in  keeping 
the  lower  part  of  his  body  erect.  For  the  return  movement, 
which  is  made  without  any  pause,  H.  reverses  the  position 
of  his  hands  quickly,  and  resists  the  movement  with  both 
hands,  but  chiefly  with  the  right.  His  hands  are  now 
in  position  to  resist  the  movement  of  bending  to  the  right, 
which  is  proceeded  with  after  a  short  pause,  and  when  the 
exercise  is  completed  his  hands  are  in  the  same  position  as 
they  were  at  starting.] 


FIG    37 


n6 


Fio.  38 


No.  26.     Figs.  37  and  38. 

G.  stands  with  his  feet  together  in  the  military  position  of 
attention.  H.  stands  close  by  him  and  lays  one  hand  on 
the  middle  of  his  chest  (Fig.  37) ;  the  other  hand  rests  on  his 
back,  between  his  shoulder-blades  (Fig.  38).  G.  then  bends 
his  head  and  chest  forwards.  H.  offers  no  resistance,  but 
only  prevents  any  actual  forward  movement  taking  place 
from  the  hips.  The  extent  to  which  G.  should  bend  his 
head  and  chest  is  personal,  and  depends  upon  the  amount  of 
exertion  which  it  is  desirable  he  should  have.  That  being 
reached,  he  returns  slowly  and  without  any  pause  between 
the  movements  to  his  original  position  at  starting. 


n8 


12O 


FIG.  40 


121 


No.  27.     Figs.  39  and  40. 

G.  stands  erect,  but  holds  himself  as  laxly  as  possible.  H. 
places  himself  opposite  G.'s  right  side  and  places  his  right 
hand  on  the  pit  of  G.'s  stomach  (epigastrium),  Fig.  39  ;  his 
other  hand  is  placed  on  G.'s  back,  between  the  shoulder- 
blades,  Fig.  40.  G.  then  bends  the  upper  part  of  his  body 
backwards.  To  this  H.  offers  no  resistance  whatever,  but 
only  steadies  the  patient  and  prevents  the  bending  back- 
wards being  carried  so  far  as  to  cause  straining.  The  extent 
to  which  G.  may  bend  backwards  is  personal,  and  depends 
on  the  amount  of  exertion  he  may  be  permitted  to  have. 
That  being  reached,  G.,  without  any  pause  and  without 
any  resistance  whatsoever  on  the  part  of  H.,  returns  slowly 
to  the  erect  position. 


122 


124 


No.  28.     Figs.  41  and  42. 

G.  lies  comfortably  on  a  couch  and  pushes  his  feet  through 
a  leather  stirrup  attached  to  a  footboard  in  the  manner  shown 
in  Fig.  41.  The  footboard  is  thus  held  firmly  in  its  position. 
G.  takes  hold  of  the  cross-bar  of  the  apparatus  with  both 
hands  and  pulls  it  till  the  springs  are  tightly  stretched. 
Then  by  a  series  of  forward  and  backward  movements  of  his 
body,  during  which  the  springs  are  alternately  relaxed  and 
tightened,  he  brings  himself  into  a  sitting  position.  During 
the  process  of  raising  himself  he  must  keep  his  lower  limbs 
fully  extended,  and  must  not  bend  his  knees  even  to  the 
smallest  extent.  When  in  the  sitting  position  he  takes  a  few 
deep  breaths.  After  that  he  permits  his  body  to  fall  back 
gently  to  the  recumbent  position  by  dint  of  stretching  the 
springs  and  pressure  of  his  extended  limbs  against  the  foot- 
board (see  Fig.  42).  Again  there  is  a  breathing  pause. 

This  exercise  is  not  included  amongst  the  general  gym- 
nastic exercises,  but  should  be  practised  as  a  special  one. 
It  is  particularly  suitable  for  patients  suffering  from  con- 
stipation and  flatulency. 


INDEX 


Abduction  of  Lower  Limbs,  50,  51 
Abduction    and    Rotation    of    Lower 

Limbs,  52,  53 
Action  of  Drug's,  6,  7 
Action  of  Physical  Methods,  6,  7 
Active  Gymnastics,  32 
Acute  Dilatation  of  Heart,  21 
Alcohol  in  Heart  Affections,  39 
Alternating'  Current  Baths,  22 
Apoplexy,  Use  of  Baths  and  Exercises 

in,  5 
Arm  Abduction,  46,  47 

Arterio-Sclerosis  and  Physical  Treat- 
ment, 5 
Auscultation  of  Heart,  20 

Backward  Stretching  of  Arms,  78,  79 
Blood-Pressure,  Directions  for  deter- 
mining', 18 
Bradycardia,   14 
Breathing'  during  Gymnastics,  37 

Carbonic  Acid  Baths,  ix 

Care  required  in  prescribing  Physical 

Treatment,  9 

Clothing  during  Gymnastics,  38 
Cooling  Tubes  for  Baths,  38 

Danger  of  Physical  Methods  used  by 

Unqualified  Persons,  x 
Deceptive  Dilatation  of  Heart,  21 
Diet  during  Gymnastic  Course,  38 
Difficulties    in    Sending    Patients    to 

Bad-Nauheim,  viii 
Directions  for  Gymnastic  Exercises, 

4i 
Directions  for  taking  Blood-Pressure, 

18 

Doing  too  much,  i 
Drugs    versus    Physical    Methods    of 

Treatment,  6 


Effects  of  Gymnastics  on  Blood-Pres- 
sure, 18,  19 

Effects  of  Gymnastics  on  Irregular 
Pulse,  14,  17 

Errors  in  Performance  of  Gymnas- 
tics, x 

Extenso-flexion  of  Forearm,  64,  65 
Extension  of  the  Leg,  88-91 
External  and  Upward    Stretching  of 
Arms,  74-7 

Flexion  of  Forearm,  62,  63 
Flexion  of  Leg  and  Thigh,  54-7 
Forearm  Bending,  42-5 
Forward  Thrusting  of  Forearms,  80,  8 1 
Forward  and   Upward  Stretching  of 
Arms,  70-3 

Graupner,  22,  27 

Gymnastics  in  After  Treatment  of 
Heart  Weakness,  6 

Herz,  2,  33 

Horizontal  Extension  of  Arms,  66-9 

Importance  of  Physical  Methods,  vii 
Instructions    of    Physician    must    be 

closely  followed,  3 
Irregular  Pulse,  14 

Klemperer,  27 

Knee  Abduction  and  Adduction,  92-5 

Kraus,  22 

Leg  Flexion,  96,  97 

Leg-Raising    Sideways    (Abduction), 

106-9 
Lightening  the  Work  of  the  Heart,  7 

Medical  Supervision,  viii,  9,  33 
Moritz's     Symptom     of     Strain     and 

Exhaustion,  20,  21,  24 
Muller  Exercises,   i 


128 


INDEX 


Object  of  Gymnastics,  36 
Observations  on  the  Pulse,  10 
Observing  Effects  of  Gymnastics,  10 
Oertel  Terrain  Cure,  2 
Order  of  Gymnastic  Course,  35 
Oxygen  Baths,  22 

Passive  Gymnastics,  31 
Pathognostic  Blood-Pressure  Curves, 

-27 

Percussion  of  Heart,  20 
Phases  of  Movement,  23 
Physical  Methods  most  useful  in  Early 

Stages,  4 
Physical  Methods  must  be  supervised 

by  Physician,  viii,  9 

Principal  Systems  of  Gymnastics,  i 

Raising  Lower  Limbs,  58,  59 

Reduction  of  Obesity,  8 

Reduction    of    Pulse     Frequency    by 

Gymnastics,   14 

Reduction  of  Silhouette  of  Heart,  22 
Remedial     Gymnastics     suitable    for 

some  cases  only,  i 
Researches  on  Blood- Pressure,  18 
Resistance  Gymnastics,  32 
Respiration,  Observations  on,  28 
Rest  required  with  Physical  Methods, 

7 
Riva-Rocci's  Method   of  determining 

Blood- Pressure,  18 
Rotation  of  Extended  Arm,  86,  87 
Rotation  of  Feet,  48,  49 
Rotation  of  Upper  Arm,  82-5 
Rumpf  s  Method,  27 


Self-performed  Gymnastics,  32 

Self-resisted  Gymnastics,  33 

Scepticism  regarding  Physical  Me- 
thods, viii 

Schott,  August,  viii,  xi 

Selection  of  Cases  for  Physical  Treat- 
ment, 4 

Selection  of  most  suitable  system  of 
Remedial  Gymnastics,  3 

Sommer's  Analysis  of  Motion,  23, 
34 

Swedish  Remedial  Gymnastics,  2 

Systems  of  Gymnastics  for  Heart 
Affections,  i 

Thigh  Extension,  102-5 
Thigh  Flexion,  98-101 
Time  required  for  Exercises,  36 
Translator's    Preface    and    Introduc- 
tion, vii 

Trunk  Bending,  36 
-  backwards,  118-21 

—  forwards,   114-17 

—  sideways,  112,  113 

—  twisting,  108,  11 1 

—  raising,  60,  61,  122-5 

Unsuitable  cases  for  Physical  Me- 
thods, 4 

Various  Conditions  of  Blood-Pressure 
after  Gymnastics,  18 

X-rays  Examination  of  Heart,  20 
Zander  System  of  Gymnastics,  3 


WILLIAM    BKKNDON    AND   SON,    LTD. 
PRINTERS,    PLVMOUTH 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-10w-6,'52(A1855)444 


721 

H67E    Hofmann  •' 

Remedial  gymnast  1' 
for  heart  affections 


*RM 
721 
H6?E 


I  I'll  in  ri ii 

A    001410723 


